NCC224205_FRO Submitted_20221229

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 NIA in the blank.)
Part A.
1. Project Name Carolina Land and Lakes Resource Conservation & Development, Educational Warehouse
2. Location of land -disturbing activity: County Alexander City or TownshipTaylorsvllle
Payne's Dairy Road, SR 1624 N-35.839 W-81.150
Highway/Street Latitudeideamal degrees) Longitude�de<;mal degrees}
3. Approximate date land -disturbing activity will commence: Summer, 2022
4. Purpose of development (resid4ntial, commercial, industrial, institutional, etc ): Educational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.4 Acres
6. Amount of fee enclosed: $ 1,500.00 . 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity -
Name
Jack Simms Email Address [e-mail]
Phone: office # 828-244-8722 Mobile # [phone]
9
Landowner(s) of Record (attach accompanied page to list additional owners):
Carolina land and lakes Resource Conservalion & Development 828-244-8722
Name Phone: Office #
P.O. Box 2977 815 Virginia Street
Current Mailing Address Current Street Address
Lenoir, NC 28645 Lenoir, NC
City State Zip City
10, Deed Book No. 650 Page No.1348
State
828-312-2575
Mobile #
28645
Zip
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).
Carolina Land and Lakes Rosounce conservation and Development
Company Name
P.O. Box 2977
Current Mailing Address
Lenoir, NC 28645
City State Zip
Phone- Office # 828-244-8722
[e-mail]
E-mail Address
815 Virginia St.
Current Street Address
Lenoir, NC 28645
City State Zip
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:
Melissa Patton
Name of Registered Agent
P.O. Box 2977
Current Mailing Address
Lenoir, NC 28645
City State Zip
www.carolinalandandlakes.com
E-mail Address
815 Virginia Avenue
Current Street Address
Lenoir, NC 28645
City
Phone. office # 828-244-8722 Mobile # [phone]
Jack Simms
Name of Individual to Contact (if Registered Agent is a company)
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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
Carolina Land and Lakes Resource Conservation and Development
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,
Jack Simms Project Manager
Type orpjint na Title or Authority
Signature Date
--------------------------------------------------------------------------------------------------------------
I, l C)\'&"_ N . �C r1c21 , a Notary Public of the County of k\ Q)co.'-'C� e r
State of North Carolina, hereby certify that rc. appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this �5`161 day of , 24 a2_
`,,�111111ff/�
a4A t Not
My commission expires oibaZ

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 # Wo`biile #
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 Stale 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 Stale
Phone: Office # Mobile #
Zip
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City Stale Ziz)
Phone: Office # Mobile #
Company 5 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone- Office # Mobile #
23