NCC222496_FRO Submitted_20220712

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Blue Ridge Healthcare Morganton Campus Improvements
1. Project Name g 9 P P
2
Location of land -disturbing activity: County Burke
City or Township Morganton
Highway/Street S Sterling St/NC Hwy 18 Latitude 35.725333 Longitude -81.655687
3. Approximate date land -disturbing activity will commence: July 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.2 acres
6. Amount of fee enclosed: $ $650.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Deanne Avery E-mail Address [e-mail]
1110
Telephone [phone] Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Blue Ridge Healthcare Hospitals, Inc. 828-580-1127
Name Telephone Fax Number
2201 S. Sterling St
Current Mailing Address Current Street Address
Morganton NC 28655
City
Deed Book No. 258
State Zip City
State
93
Page No. 523, 562 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Blue Ridge Healthcare Hospitals, Inc.
Name
2201 S. Sterling St
Current Mailing Address
Morganton NC 28655
City
[e-mail]
E-mail Address
Current Street Address
State Zip City
Telephone [phone] Fax Number.
State
0

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Thomas Eure
Name of Registered Agent
2201 S. Sterling Street
Current Mailing Address
Morganton, NC 28655
City
State Zip
Telephone [phone]
E-mail Address
2201 S. Sterling Street
Current Street Address
Morganton, NC 28655
City State Zip
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
-j,,UyVNOLS L , G u,,e Authorized Representative
Type or print name Title or Authority Jrt. NI.P. Corporc6e Sevw icy, gr
r"k 1 TILI 11b C�ev►erw� �Cwt.tsC)
Signature Date
I, j-P SS i c..a- �--owrvna4, , a Notary Public of the County of IS".rVe,
State of North Carolina, hereby certify that _T"hO''rnOL5 �-- C—u re.. appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
'�/111#110#0 St -
Witness
my��it��q! *n(dOq traI seal, this �l day of J-W , 20 X-1
`,. G '�,,.......,. �t�. '.
NOTARY %J� cam. o�ee.1.Y,no�.J
aGS,eFa'IUBLIC .:
Notary
.
OUN����. My commission expires �--� i �s
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