NCC230326_FRO Submitted_20230207

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 Jonas Ridge Convenience Center and Park Phase 1
2. Location of land -disturbing activity: County Burke City or Township Jonas Ridge
N C Hwy 181 35.961542-81.889790
Highway/Street _ LatltUde(decimaldegrees) Long ltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence: 1 1 /01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public Services
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.62
6. Amount of fee enclosed: $ 300 . 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 ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Alan Glines E-mail Address alan.gllnes [e-mail]
Phone: Office # 828-764-9032 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Burke County 828-764-9030
Name Phone: Office # Mobile #
200 Avery Avenue 200 Avery Avenue
Current Mailing Address Current Street Address
Morganton, NC 28655 Morganton, NC 28655
City State Zip City State Zip
10. Deed Book No. 2552/2413/2626/2609 Page No. 28/89/648/732 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Burke County
Company Name
200 Avery Avenue
Current Mailing Address
Morganton, NC 28655
E-mail Address
200 Avery Avenue
Current Street Address
Morganton, NC 28655
City
State Zip
City
Phone:
Office # 828-764-9000
Mobile #
State
Zip
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:
N/A
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)
(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:
N/A
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.
County Manager
Type or rint name Title or Authority
09 /Y- J�Zv
Signature Date
i, { kia I'tA`pT' r� u.(a� kVL a Notary Public of the County of sI ,Ly K.C.
State of North Carolina, hereby certify that � jp.h V#'-7 F;1 . SPlM�'l appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by himl-ker.
-I6-•
Witness my hand and notarial seal, this _day of 20 ZZ
Notar
Seal , �S 2o2Z
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My commission expires L.X_`ti .
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AUNTY, NG�°`°
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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.
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 8 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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
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
State Zip
State Zip
State Zip
City State Zip City State Zip
Phone: Office # Mobile #