NCC222654_FRO Submitted_20220727

APPENDIX D
FINANCIAL RESPONSIBILITY /OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate a 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, NC Department of Environment, and Natural Resources. (Please type or print and, if question is not
applicable, place N/ A in the blank).
Part A.
1. Project Name Poplar Forest Development
2. Location of land -disturbing activity: County Watauga
City or Township Boone , and Highway/Street Howard's Creek
3 Approximate date land -disturbing activity will be commenced:
4. Purpose of development (residential, commercial, industrial, etc): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
17.71
2,
Amount of fee enclosed $ 2,656.5
Has an erosion and sedimentation control plan been filed? Yes No
Enclosed x
8. Person to contact should sediment control issues arise during land -disturbing activity.
Name Derek Buchanan Telephone [phone]
9 Landowner(s) of Record (Use blank page to list additional owners):
Poplar Forest, LLC 19421 Liverpool Parkwary
Name(s)
Cornelius NC, 28031
Current Street Address
Book 2256 Page 387(9)
10. Page No.
Part B.
Person(s) or firm(s) who are financially responsible for this land -disturbing activity (Use a blank page to list
additional persons or firms):
Poplar Forest, LLC
Name of Person(s) or Firm(s)
19421 Liverpool Parkway
Current Mailing Address Current Street Address
Cornelius, NC 28031
City State Zip City State zip
Telephone [phone] Telephone

2. (a) If the Financially Responsible Party is not a resident of North Carolina give name and street address of a
North Carolina Agent.
Name
Mailing Address
Street Address
city State Zip City State Zip
Telephone
Telephone
(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.
Name of Registered Agent
Mailing Address Street Address
city State Zip City State Zip
Telephone Telephone
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 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.
William N. Adkins "embe.- Man Y9t2
Type or print name Title or Authority
--
Signature Date
1, n / i 7yi e Z�ji 1,541 _,a Notary Public of the County of /,l eel /eI� ✓" y
State of North Carolina, hereby certify that A 1ll;%Y" /` .
appeared personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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