NCC230828_FRO Submitted_20230329

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 RIVERSTONE (LOT #3)
2. Location of land -disturbing activity: County RUTHERFORD City or Township HIGH SHOALS
BROAD RIVER BLVD 35.21518-81.84418
Highway/Street Latltude(decima�degrees) Lorig itude{decimaldegrees)
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): COMMERCIAL
5_ Total acreage disturbed or uncovered (including off -site morrow and waste areas): 8.94 ACERS
6. Amount of fee enclosed: $ 900 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 $940).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name LUCAS TOLLEY E-mail Address [e-mail]
Phone: office # 528-247-4495 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
RIVERSTONE 3 LLC
Name
10620 TREENA ST
Phone: Office #
10620 TREENA ST
619-696-7355
Mobile #
Current Mailing Address Current Street Address
SAN DIEGO CA 92131 SAN DIEGO CA 92131
City State Zip City State Zip
10. Deed Book No. 2051 Page No. 1971 Provide a copy of the most current deed.

Part B.
9. 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 names) of the owner(s) may be fisted as the financially responsible party(ies).
RIVERSTONE 3 LLC
Company Name
10620 TREENA ST
Current Mailing Address
SAN DIEGO CA 92131
btabb aaenvdev.com
E-mail Address
10620 TREENA ST
Current Street Address
SAN DIEGO CA 92131
City State Zip City State Zip
Phone: Office # 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 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:
Corporation Service Company
Name of Registered Agent
2626 Glenwood Avenue Suite 550
Current Mailing Address
Raleigh NC 27608
City State Zip
Phone: Office #
E-mail Address
2626 Glenwood Avenue Suite 55
Current Street Address
Raleigh NC 27608
City State Zip
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
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.
Bruce Tabb
Type or print name
Signature
owner
Title or Authority
1211122
Date
a Notary Public of the County of
State of North Carolina, hereby certify that _ _ _1��Y_ �L�, appeared personally
before me this day and being duly sworn acknowledged thawwabove form was executed by him/her.
Witness my hand and notarial seal, this I day of 20_ z
No
B S"ott Roach
PUBLIC My commission expires
d County, NC
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ComrExpires ,tune 08, 2026