NCC240168_FRO Submitted (2)_20240209

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 LIME KILN RV PARK
2. Location of land-disturbing activity: County Transylvania City or Township Pisgah Forest
Highway/Street 200 Lime Kiln Ln Latitude(decimal degrees)35.315908 Longitude(decimal degrees) -82.654691
3. Approximate date land-disturbing activity will commence: July 30, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.0
6. Amount of fee enclosed $1,400.00 . 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 ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matthew Poirier E-mail Address poirier.matt(c�gmail.com
Phone: Office# 408-332-6600 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Lime Kiln Lane, LLC 408-332-6600 408-332-6600
Name Phone: Office# Mobile#
865 Dakota Drive 865 Dakota
Current Mailing Address Current Street Address
Auburn AL 36832-6101 Auburn AL 36832-6101
City State Zip City State Zip
10. Deed Book No. 1044 Page No. 249-251 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 name(s)of the owner(s)may be listed as the financially responsible party(ies).
Lime Kiln Lane, LLC [e-mail]
Company Name E-mail Address
865 Dakota Drive 865 Dakota Drive
Current Mailing Address Current Street Address
Auburn AL 36832-6101 Auburn AL 36832-6101
City State Zip City State Zip
Phone: Office#408-332-6600 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:
Merrell,Jennifer poirier.matt(c�gmail.com
Name of Registered Agent E-mail Address
77 E. Main Street 77 E. Main Street
Current Mailing Address Current Street Address
Brevard NC 28712-3712 Brevard NC 28712-3746
City State Zip City State Zip
Phone: Office# 408-332-6600 Mobile# [phone]
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:
T.E. ALLEN ENGINEERING, PC teallenenq(a�comporium.net
Engineering firm or other consultant E-mail Address
Terry E. Allen, PE 828-553-3004 828-553-3004
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.
Type or print name Title or Authority
Signature Date
I, , a Notary Public of the County of
State of North Carolina, hereby certify that 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 day of , 20
Notary
Seal My commission expires

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #