NCC222535_FRO Submitted_20220803

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Off The X Training Solutions EC Plan
2. Location of land -disturbing activity: County Rutherford City or Township Rutherfordton
Highway/Street696 Jonas Road Latitude(decimal degrees) 35.191088 Long itude(decimaldegrees) -81.917559
3. Approximate date land -disturbing activity will commence: 5/1 5/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Shooting range
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.6 AC
6. Amount of fee enclosed: $400.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
0
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name William F. McBrayer E-mail Address [e-mail]
Phone: Office # 828-429-9787 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Adam Wayne & Wife Pamela Ann Crumpton 828-462-3453 828-755-1250
Name
696 Jonas Road
Current Mailing Address
Rutherfordton NC 28139
Phone: Office # Mobile #
696 Jonas Road
Current Street Address
Rutherfordton NC 28139
City State Zip City State Zip
10. Deed Book No. 1112 Page No. 150 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
OFF THE X TRAINING SOLUTIONS L.L.C.
Company Name
696 Jonas Rd
Current Mailing Address
Rutherfordton NC
[e-mail]
E-mail Address
696 Jonas Rd
Current Street Address
28139 Rutherfordton NC 28139
City State Zip City State Zip
Phone: Office # 828-755-1250 Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Legalinc Corporate RA Services Inc.
Name of Registered Agent
8480 Honeycutt Road, Ste 200 #V295
Current Mailing Address
Raleigh NC
City State
E-mailAddress
8480 Honeycutt Road, Ste 200 #V295
Current Street Address
27615 Raleigh
Zip City
Phone: Office # 8
qq gj G I Mobile #
F-4kct n
Name of Individual to Contact (if Registered Agent is a company)
NC 27615
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Pamela Ann Crumpton Member
T print name Title or Authority
7 4/14/20
ignature Date
a Notary Public of tie County of
State of North Carolina, hereby certify that I OL MV-AS k rl&V\I-,EVMtli0Kkpeared personally
before me this day and being duly sworn acknowledged that the above form executed by him/her.
Witness my hand and notarial seal, this day of 1 20�
1'
Notary
Sea1
My commission expires C ;?O;Z

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
State Zip
State Zip