NCC231933_FRO Submitted_20230627

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 and/
or fax information unavailable, place N/A in the blank.)
Part A.1. Project Name Eastern Convenience Site
2. Location of land-disturbing activity: County Burke City or Township Icard
Highway/Street US Hwy 70 Latitude 35.723199 Longitude-81 .463857
3. Approximate date land-disturbing activity will commence:March 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.9 acres
6. Amount of fee enclosed: $600.00 . The application fee of$65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Alan Glines E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Burke County 828-764-9350
Name Telephone Fax Number
PO Box 219
Current Mailing Address Current Street Address
Morganton NC 28680 Morganton NC 28655
City State Zip City State Zip
10. Deed Book No.2566 Page No. 175 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Burke County [e-mail]
Name E-mail Address
PO Box 219 200 Avery Avenue
Current Mailing Address Current Street Address
Morganton NC 28680 Morganton NC 28655
City State Zip City State Zip
Telephone [phone] Fax Number 828-764-9352

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Brian Epley County Manager
Type or print name Title or Authority
2/17/2023
Signatur Date
I, \ - ��� , a Notary Public of the County of ,rke,
State of North Carolina, hereby certify that lairicirr E appeared
personally before me this day and being duly sworn acknowled ed that the above form was
executed by him.
Witness my hand and notarial seal, this /7 day of Fp_hruc -u , 20 .3
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