NCC223980_FRO Submitted_20221206

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 NIA in the blank.)
Part A. MFG - Tweetsie Underpass
1. Project Name
2. Location of land -disturbing activity: County Watauga City or Township Blowing Rock
Highway/Street US Highway 321 Latitude 36.170679 Longitude-81.645882
3. Approximate dale land -disturbing activity will commence: May 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 0.60 acres
6. Amount of fee enclosed: $ 100.00 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Wendy Patoprsty, Blue Ridge Conservancy E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Watauga County 828-265-8043 (Joe Furman)
Name Telephone Fax Number
126 Poplar Grove Connector, Suite 201
Current Mailing Address Current Street Address
Boone NC 28607
City State Zip City State Zip
10. Deed Book No. 2212 Page No. 249 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.
Watauga County [e-mail]
Name E-mail Address
126 Poplar Grove Connector Suite 201
Current Mailing Address Current Street Address
Boone NC 28607
City State Zip City State Zip
Telephone [phone] (Joe Furman) 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:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip 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
61
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Type or print name Title or Authority
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a Notary Public of the County of�
State of North Carolina, hereby certify that SZOW l f� '1 VttirnCX 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 SJ %� day of OLAW' , 20 22
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tary
My commission expires �'��?_p2'