NCC230864_FRO Submitted_20230330

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 NameLEFS MCRAE COLLEGE - HISTORIC COMMONS
2. Location of land -disturbing activity: CountyAVERY City or Township 13ANN ER ELK
COLLEGE DR 36.16083-81.8765
HighwaylStreet Latitude�aeamaidear�as� Langitudetaed�idegreeg>
3. Approximate date land -disturbing activity will commence: 11101/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): INSTITUTIONAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas),4
6. Amount of fee enclosed: $400.00 . 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:
NameBLAINE J. HANSEN E-mall Address [e-mail]
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LEES-MCRAE COLLEGE, INCORPORATED
Name Phone: Office # Mobile #
191 MAIN STREET WEST
Current Mailing Address
BANNER ELK, NC 28604
City
State
10. Deed Book No. 421, 163, 128 page
Current Street Address
Zip City State Zip
No 684, 764, 690 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 names) of the owners) may be fisted as the financially responsible party(les).
LEES-McRAE COLLEGE, INCORPORATED
Company Name E-mail Address
191 MAIN STREET WEST
Current Mailing Address Current Street Address
BANNER ELK, NC 2$604
City State Zip City State Zip
Phone: Office # Mobile #
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:
KIM R. BAUMAN
Name of Registered Agent
1912 EASTCHESTER DRIVE, SUITE 400
Current Mailing Address
HIGH POINT, NC 27265
City State Zip City
Phone: Office # _ Mobile #
E-mail Address
Current Street Address
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
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.
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.
BLAINE J. HANSEN
Ty r rint name
Si to
VICE PRESIDENT FOR PLANNING AND
EXTERNAL RELATIONS
Title or Authority
7j ?,t ( 2,5
Date
I, I&ILAd2 C � 4r� , a Notary Public of the County of.- (�j
- i
State of North Carolina, hereby certify that ejaxa"J 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 a g day of • =u 202_
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My commission expires 15 92n, ab,;Z %