NCC233175_FRO Submitted_20231027

(1142)
NENDE ON ,LINTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM HENDER50CUNT),
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 Henderson County Site Development Department. (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.)
Sign the original form in BLUE INK.
Part A.
1. Project Name Copart- Fletcher
2. Location of land-disturbing activity: County Henderson City Fletcher
Highway/StreetMills Gap Rd (SR 1551) Latitude35.433861 Longitude 82.48775
Property Identification Number(s) PIN's 9663102350
3. Approximate date land-disturbing activity will commence:9/1/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):38.50
6. Amount of fee enclosed: $1 1 1900 . The application fee of$300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac=$2,900.00).
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Eric Trumbach E-mail [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Copart of Connecticut, Inc. [phone]
Name Telephone
14185 Dallas Parkway 14185 Dallas Parkway
Current Mailing Address _ Current Street Address
Dallas TX 75254 Dallas TX 75254
City State Zip City State Zip
10. Deed Book No.3981 Page No.387 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.
Cape-C4 o Cot,„ec �<A•F, 1�
Name + E-mail Address
1 ( /95- a`I�tis Ar466,I6,7/ i.�i 300
Current Mailing Address Current Street Address
balla S / aSy
City \ State Zip City State Zip
Telephone q 7�) 311 5-037 Fax Number

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:
Co Pee, kor► SeiVt.e..- (tOievipart%7
Name E-mail Address
ea G )c 6 ier;D e, Ave, S ;� bb
c
Current Mailing Address Current Street Address
4Li1.11 N6 )7408
City State Zip City State Zip
Telephone
(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
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.
G> 2y ��zol,aNA icE. atDa.i-IT
Type or -int name Title or Authority
Signa Date
I, A/Y tito a L C-1647 ,(L3 , a Notary Public of the County of 00,(51„.
State of t-ea5 , hereby certify that OlttY4 XOi n
appeared personally before me this day and being duly s orn acknowledged that the above
form was executed by him.
Witness my hand and notarial seal, this 114* day of -fr , 20 13
1 oFf AMANDA GO .ALS 1
r �; ,�`a pyCgMMISSIlNEXPIRES 1 otary
'' `" S ANUARY 22,2025 1
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., . NOTARY ID: 1222022-3 ► My commission expires j,tV