NCC242522_FRO Submitted_20240823

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Swannanoa Greenway - Segment 1
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Buncombe City or Township Asheville
Highway/Street Thompson St Latitude(decimal degrees) LongitUde(decimaidegrees)
3. Approximate date land-disturbing activity will commence:July 1 , 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): public amenity
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.4
6. Amount of fee enclosed: $900 . The application fee of$100.00 per acre (rounded
up to the next acre)is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dustin Clemens E-mail Address dclemens@ashevillenc.!
Phone: Office# 828-575-3851 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
SWANNANOA GARDEN SALON LLC 828.412.5193 917.239.6362
Name Phone: Office# Mobile#
52 MULVANEY ST 52 MULVANEY ST
Current Mailing Address Current Street Address
ASHEVILLE, NC, 28803 ASHEVILLE, NC, 28803
City State Zip City State Zip
10. Deed Book No.5425 Page No.0905 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).
City of Asheville [e-mail]
Company Name E-mail Address
70 Court Plaza P.O. Box 7148 70 Court Plaza P.O. Box 7148
Current Mailing Address Current Street Address
Asheville, NC, 28804 Asheville, NC, 28804
City State Zip City State Zip
Phone: Office# 828-575-3851 Mobile#
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 II
•
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
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.
DC . ��.�✓JAS' C z T+h P10C ;-s ,z �fid��
Type or print name Title or'Authority
Z'5.--"/V2_0 2 2
gnature Date
I, ,iv,At , a Notary Public of the County of T- ,eo,u.9,E,
State of North Carolina, hereby certify that S 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 \°rk` day of C1‘ivi , 20 3
N y
Seal
My commission expires
Michelle F. Smith
NOTARY PUBLIC
Buncombe County
North Carolina
My Commission Expires 2-18-2027

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:
ASHBROOK PROPERTIES LLC 910-431-9036
Name Phone: Office# Mobile#
99 AMBLER RD 27 Mulvaney St
Current Mailing Address Current Street Address
ASHEVILLE, NC, 28805 Asheville, NC 28803
City State Zip City State Zip
Deed Book No.6288 Page No.081 9 Provide a copy of the most current deed.
Landowner 3 of Record:
SWANNANOA BEND LLC 828.338.8178
Name Phone: Office# Mobile#
PO BOX 1918 41 Simpson St
Current Mailing Address Current Street Address
ASHEVILLE, NC, 28802 Asheville, NC 28803
City State Zip City State Zip
Deed Book No. 5502 Page No.0353 Provide a copy of the most current deed.
Landowner 4 of Record:
THREE MOUNTAINEERS INC
Name Phone: Office# Mobile#
23 WINDSOR RD 40 Simpson St
Current Mailing Address Current Street Address
ASHEVILLE, NC, 28804 Asheville, NC 28803 . .
City State Zip City State Zip
Deed Book No.0611 Page No.0569 Provide a copy of the most current deed.
Landowner 5 of Record:
RIVER HILLS PROPERTY LLC 205-421-9500
Name Phone: Office# Mobile#
2829 2ND AVE S STE 310 105 River Hills Rd
Current Mailing Address Current Street Address
BIRMINGHAM, AL, 35233 Asheville, NC 28805
City State Zip City State Zip
Deed Book No. 5716 Page No. 1867 Provide a copy of the most current deed.

Landowner 6 of Record
Name—TEACHERS RETIREMENT SYS OF KENTUCKY
Phone: Office#—828.301.6759
Mobile If—
Current Mailing Address—C/O WALMART/PROP TAX DEPT 0555 BENTONVILLE,AR, 72712
Current Street Address—125 Bleachery Blvd Asheville, NC 28805
Deed Book No.—3936
Page No.—0419
Landowner 7 of Record
Name— HORNE DEVELOPMENT RIVER BEND LLC
Phone: Office#— 865-560-1100
Mobile if—
Current Mailing Address—412 N CEDAR BLUFF RD STE 205, KNOXVILLE,TN,37923
Current Street Address—99999 Bleachery Blvd,Asheville, NC 28803
Deed Book No.—3463
Page No.—0518