NCC232582_FRO Submitted_20230825

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 DPS- NCNG Morganton Regional Readiness Center Phase II: New Construction
2. Location of land-disturbing activity: County Burke City or Township Morganton
Highway/Street 5155 Western Avenue Latitude 35.68° N Longitude 81.68°W
3. Approximate date land-disturbing activity will commence: June 2020
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional/Military
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 34.4-acres
6. Amount of fee enclosed: $2,275.00. 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_ ✓_
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Harold Litzenberger E-mail Address haroldC7a.ipd-design.com
Telephone [phone] Cell#919-274-9720 Fax# None
9. Landowner(s)of Record (attach accompanied page to list additional owners):
State Hospital (at Morganton) 919-855-4880 919-733-5711
Name Telephone Fax Number
2201 Mail Service Center 820 S. Boylan St
Current Mailing Address Current Street Address
Raleigh NC 27699 Raleigh NC 27603
City State Zip City State Zip
10. Deed Book No. 66 Page No. 91 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.
Hickory Construction Company N/A
Name E-mail Address
PO Box 1769 352 2nd Street, NW Suite 201
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28601
City State Zip City State Zip
Telephone [phone] Fax Number 828-322-5138

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.
C. Mark Baucom President/CEO
Type or print name Title or Authority
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Signature Date
l etc 1V1 , T rIVc9 Y , a Notary Public of the County of e b
State of North Carolina, hereby certify that £ . ����k 3 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this AL day of a .54. , 20 013
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