NCC230406_FRO Submitted_20230214

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 Bat Fork Stream Restoration
2. Location of land -disturbing activity: County Henderson City or Township East Flat Rock
4037 Haywood Rd 35.288185-82.409747
Highway/Street LatltUde(decima� degrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: February 20, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Stream Restoration
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0
6. Amount of fee enclosed: $ 500 . 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 x❑ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Greg Jennings E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HENDERSON COUNTY HABITAT FOR HUMANITY, INC [phone]
Name Phone: Office # Mobile #
1111 KEITH ST
Current Mailing Address Current Street Address
Hendersonville NC 28792
City State Zip City State Zip
10. Deed Book No. 1 040 Page No. 464 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Baker Grading & Landscaping, Inc. [e-mail]
Company Name E-mail Address
1000 Bat Cave Road 1000 Bat Cave Road
Current Mailing Address Current Street Address
Old Fort, NC 28762 Old Fort, NC 28762
City State Zip City State Zip
Phone: Office # (� Mobile
828 668-5060 x. 11 828 318-5635
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:
Mark Baker
Name of Registered Agent
1000 Bat Cave Road
Current Mailing Address
Old Fort, NC 28762
City State Zip
Phone: Office # [phone]
mark bakergrading.com
E-rnail Address
1000 Bat Cave Road
Current Street Address
Old Fort, NC 28762
City State Zip
[phone]
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:
Name of Registered Agent
Current Mailing Address
City
State
E-mail Address
Current Street Address
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.
Charles Baker
Type or pri
rL
Signature
Vice President
Title or Authority
/O 2
Date
I, A,kGr a Notary Public of the County of J&AAcorAhc
State of North Carolina, hereby certify that ah rle5 2>aAer appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my�h��pgand�notarial seal,
'kV : Y.. - eq
�O TA "Y
c 03
this 10 day of Ve6rup_C 20Q_
Notary
My Commission Fxpim
My commission expires August 19, 2024

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:
HENDERSON COUNTY HABITAT FOR HUMANITY, INC [phone]
Name Phone: Office #
1111 KEITH ST
Current Mailing Address Current Street Address
Hendersonville NC 28792
City State Zip City State Zip
Deed Book No. 1419 Page No. 348 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City State Zip
Deed Book No. Page No.
Landowner 4 of Record:
Phone: Office #
Current Street Address
Mobile #
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
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.

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 E-mail Address
Current Mailing Address CurrentStreetAddress
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
City
Phone: Office #
Company 5 Name
State
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Zip