NCC223767_FRO Submitted_20221115

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. EQUINE VETERINARY FACILITY
1. Project Name
2. Location of land -disturbing activity: County RUTHERFORD City or Township U N ION
Highway/Street CAMP ROAD (SR 1147) Latitude 35.30546 Longitude-82.00304
3. Approximate date land -disturbing activity will commence: UPON APPROVAL
4. Purpose of development (residential, commercial, industrial, institutional, etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.4
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 David W. Odom, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 828-429-4355 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BUCHANAN PROPERTY HOLDINGS, LLC 954-789-7783
Name Telephone Fax Number
987 OLD STONECUTTER ROAD 987 OLD STONECUTTER ROAD
Current Mailing Address Current Street Address
RUTHERFORDTON NC 28139 RUTHERFORDTON NC 28139
City State Zip City State Zip
10. Deed Book No. 2056 Page No. 1303 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.
BUCHANAN PROPERTY HOLDINGS, LLC [e-mail]
Name E-mail Address
987 OLD STONECUTTER ROAD 987 OLD STONECUTTER ROAD
Current Mailing Address Current Street Address
RUTHERFORDTON NC 28139 RUTHERFORDTON NC 28139
City State Zip City State Zip
Telephone [phone] Fax Number

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:
James B. Hogan
Name of Registered Agent
118 N. Sterling Street
Current Mailing Address
Morganton NC
City State
E-mail Address
118 N. Sterling Street
Current Street Address
28655 Morganton NC 28655
Zip City State Zip
Telephone 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.
Dr. Grace Buchanan
Type or print name
�
Signature `
Owner
Title or Authority
Date
I, Z `Q./Illt j. I: Nj V)6A&.- , a Notary Public of the County of
State of North Carolina, hereby certify that Ar(tcc El i zejiDe4F) 13t, e 7Cir7Q.P"> appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this &if)dayof j 11 lic- , 20 A
Notary
Seal
My commission expires L=LL iu_,�Qb+ J0,39