NCC233516_FRO Submitted_20231218

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 N/A in the blank.)
Part A.
1. Project Name Copper Fox Farm
2. Location of land-disturbing activity: County Polk City or Township Greens Creek
Highway/Street 7807 Poors Ford Rd Latituderdecimai degrees) 35.332 W Longitudevdeamai degrees) .81.931 N
3. Approximate date land-disturbing activity will commence: June, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Agricultural/Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas)4.2 Acres
6. Amount of fee enclosed $700 + $1050 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which
the Express Permitting supplemental fee is a fixed $2.000.00 (Example: 8.10-acre application fee is
$2.900)_ Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed X No 7
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dale Deines E-mail Address deinosaur1(c�gmail.com
Phone: Office# Mobile#[phone]
9_ Landowner(s)of Record (attach accompanied page to list additional owners):
Nicola Deines [phone]
Name Phone: Office# Mobile#
7807 Poors Ford Road SAME
Current Mailing Address Current Street Address
Rutherfordton _ NC 28139 SAME
City State Zip City State Zip
10_ Deed Book No.454 Page No.298 Provide a copy of the most current deed.

Part B.
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 name(s) of the owner(s)may be listed as the financially responsible party(ies).
Nicola Deines deinestvdesions(ayahoo corn
Company Name E-mail Address
7807 Poors Ford Road SAME
Current Mailing Address Current Street Address
Rutherfordton NC 28139 SAME
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:
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)

(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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Land Planning Collaborative [e-mail]
Engineering firm or other consultant E-mail Address
Robert M. Grasso, RLA [phone]
Individual contact person (type or print) Phone Office# Mobile#
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.
Nicola Deines Owner
Type or print nam Title or Authority
7 '.
LGcaC 09/18/2023
Si nature Date
I, , a Notary Public of the County of
State of North Carolina, hereby certify that NI c:oLok De I ,Je 3 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him/her.
tifiC
Witness my hand and notarial seal, this � ' day of 5 o , 20 Z7
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My commission expires 7 5G 20 2 c-