NCC241326_FRO Submitted_20240507

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 Townhomes At Brookshire Phase 3
2. Location of land-disturbing activity: County Watauga City or Township
Highway/Street Brookshire Road Latitude 36 13'56" N Longitude 81 38'56"W
3. Approximate date land-disturbing activity will commence: 02/01/2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_ 20.25
6. Has an erosion and sediment control plan been filed? Yes_ No Enclosed X
7. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rick Miller E-mail Address mpi(a�bellsouth.net
Telephone [phone] Cell# Fax#
8. Landowner(s)of Record (attach accompanied page to list additional owners):
RCPBD Investments. LLC _828-265-6344
Name Telephone Fax Number
PO BOX 3018 _ 324 NC Hwv 105 Ext. Suite 1
Current Mailing Address Current Street Address
Boone NC 28607_ Boone NC 28607
City State Zip City State Zip
9. Deed Book No._2095 Page No. 675 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.
RCPBD Investments. LLC 828-265-6344
Name Telephone Fax Number
PO BOX 3018 324 NC Hwv 105 Ext. Suite 1
Current Mailing Address Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip City State Zip

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:
Rick Miller mpi(dIbellsouth.net
Name of Registered Agent E-mail Address
PO BOX 3018 324 NC Hwy 105 Ext. Suite 1
Current Mailing Address Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip City State Zip
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
Corr- ted information should there be any change in the information provi d herein
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, a Notary Public of the County ofMt v
State of North Carolina, hereby certify that ,tCV, t 1��r 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
day of - k�v , 20�`
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