NCC242912_FRO Submitted_20240919

HeNDeeso FINANCIAL RESPONSIBILITY/OWNERSHIP FORM 5-HENDeE
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 NameAC PARK PARTNERS NEW WAREHOUSE
2. Location of land-disturbing activity: County HENDERSON City FLETCHER
Highway/Street LA WHITE DRIVE Latitude35.441869° Longitude-82.478625°
Property Identification Number(s) PIN's 9663337946
3. Approximate date land-disturbing activity will commence:1 1/01/23
COMMERCIAL/INDUSTRIAL
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.95
6. Amount of fee enclosed: $1700.00 . 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 SCOTT ROACH, EIT E-mail [e-mail]
Telephone [phone], ext. 13
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AC PARK PARTNERS, LLC 828-691-1472
Name Telephone
535 L A White Drive 535 L A White Drive
Current Mailing Address Current Street Address
Fletcher NC 28732 FLETCHER NC 28732
City State Zip City State Zip
10. Deed Book No.3804 Page No.456 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.
AC PARK PARTNERS, LLC [e-mail]
Name E-mail Address
535 L A White Drive 535 L A White Drive
Current Mailing Address Current Street Address
Fletcher NC 28732 Fletcher NC 28732
City State Zip City State Zip
Telephone[phone] 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:
Name E-mail Address
Current Mailing Address Current Street Address
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:
WASLAW, LLC
Name of Registered Agent E-mail Address
Post Office Box 867
Current Mailing Address Current Street Address
NEW BERN NC 28563
City State Zip City State Zip
Telephone [phone]
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.
SCOTT CLARK , Managing Partner
Typ or print Title or Auth rity
[gnat re G Date
I, 2. 'T-orl ¶oAc4 V , a Notary Public of the County of Rthile'
State of \o ( bLfj('(4 , hereby certify that Scar CLAN-
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
41
Witness my hand and notarial seal, this tv day of , 2
B Scott Roach
NOTARY PUBLIC Notary
Rutherfo&Gbunty, NC
My Commission Expires June 08,2026 My commission expires v