NCC230373_FRO Submitted_20230209

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
Project Name DKOTA
Location of land -disturbing activity: County Rutherford City or Township Forest City
Highway/Street 0 Woods Drive Latltude(decimal degrees) 36.3391 Longitude(decimai degrees)-81.8865
3. Approximate date land -disturbing activity will commence: January 31 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.44
6. Amount of fee enclosed $300 (req.) + $750 (express) = $1,050.00. The Express Permitting application
fee is a dual charge. The normal fee of $100.00 per acre (rounded up to the next acre) is assessed
without a ceiling amount. In addition, the Express Permitting supplement is $250 per acre up to eight
acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre
application fee is $2,900). 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 Kevin Caldwell E-mail Address kcaldwel[Cfteosciencegroup.com
Phone: Office # 704-941-2252 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Dkota Investments, Inc. 214-668-8194 214-668-8194
Name Phone: Office # Mobile #
4848 Lemmon Avenue, Suite 622 4848 Lemmon Avenue, Suite 622
Current Mailing Address Current Street Address
_ Dallas, Texas 75219 Dallas Texas 75219
City State Zip City State Zip
10. Deed Book No. 2062 Page No. 4735-4737 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).
Dkota Investments, Inc. russell(Wdkota.biz
Company Name E-mail Address
4848 Lemmon Avenue Suite 622 4848 Lemmon Avenue, Suite 622
Current Mailing Address Current Street Address
Dallas, Texas 75219 Dallas, Texas 75219
City State Zip City State Zip
Phone: Office # 214-668-8194 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:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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:
Northwest Registered Agent Service, Inc. support(a�northwestregisteredagent.com
Name of Registered Agent E-mail Address
4030 Wake Forest Road 4030 Wake Forest Road
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Phone: Office # 509-768-2249 Mobile # [phone]
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Geoscience Group, Inc.
Engineering firm or other consultant
Kevin Caldwell
Individual contact person (type or print)
kcaldwellfteosciencegroup.com
E-mail Address
704-942-2252 704.661.2210
Phone: Office # Mobile #
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 aupority to execute/Instruments for the Financially Responsible Party). I agree to provide
correct c! information sVq4jld there be any change in the information provided herein.
ssell Leitch) Owner resident
7or print nam Title of)yj thority
` oZ .23
Signat re Date/
I, , a Notary Public of the County of f IlaS
State of t4a, hereby certify that �4s'zt- f appeared personally
before me this day and being duly sworn acknowledged that a above form was executed by him/her.
Witness my hand and notarial seal, this a� day 20 0`
Patricia Pelfrey NO ry
!& Notary Public, State of Texas
Comm osioano2a
�_,`°`` Notary ID 13076620-5 My commission expires

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.
i n _F o___...a.
Name
Current Mailing Address
City
Deed Book No._
Name
Current Mailing Address
City
Deed Book No._
Name
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Current Mailing Address
Phone: Office #
Current Street Address
Mobile #
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
Deed Book No.
State Zip City State Zip
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
City
Phone: Office #
Company 4 Name
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
E-mail Address
Current Street Address
State Zip City
Mobile #
State Zip
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #