NCC243556_FRO Submitted_20241118

BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PLANNING & DEVELOPMENT OWNERSHIP FORM FOR AN
(828)[e-mail] EROSION CONTROL PERMIT
• www.buncombeeounty,orglplanning
INSTRUCTIONS:All sections must be completed.Section E must be CASE NUMBER
completed in the presence of a Notary Public.
Proper“ Information
PIN(Numbers): 9606-48-6826 Project Name: Rolling Hills
Latitude: 38.8348 Longitude: -82.6837 Amount of fee enclosed:$15'750'00
Project Location-Highway/Street:Un-addressed Queen Rd
Proposed Use: a Single Family Residence ❑Multi-Family ❑Vacation Rental o Commercial/Industrial/Other o Other
Proposed Disturbed Area(Include offsite borrow and waste areas): 3° acre(s)
B. Contact ltifoitnation l in:uu ialh 12ca nn,ilrlc l'or,n
Section 26-228(b)of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "Erosion control plans shall be
accompanied by a notarized statement of financial responsibility and ownership".This statement shall be signed by the person
financially responsible for the land disturbing activity or his attorney in fact.The undersigned states that he/she is the person
financially responsible for land disturbing activity described in this application and acknowledges receipt of a copy of the County of
Buncombe Soil Erosion and Sedimentation Control Ordinance and that he/she has thereby been advised of the requirements therein as
well as the penalties and resources available to the County in the event of violation of the Ordinance,including revocation of the Land
Disturbing Permit and all building permits issued in connection with the project covered by the application.
Name of Business: Queen Road Development Group,LLC Name of Applicant:Ken Jackson
Mailing Address: P.O Box 1157 Arden,NC 28704
Street address: 3 Walden Ridge Drive,Suite 300 Asheville,NC 28803
E-mail address [e-mail]
Telephone:[phone] Cell: Fax:
C. l.audmwncr(s)of 13ccnrd
Name of Landowners)of Record: cA wuis'°.ANDERS NJo1JTTRuar
Mailing Address: 2858 GREEN RIVER RD,ZIRCONIA,NC,28790
Recorded in Deed Book No: 5517/1706 Page: 0234/0002
I). Contact Inlitnuatinn North Carolina:1ycnt(.1./App/ic.,/,/e)
Section 26-228(b)of the Buncombe County Soil Erosion and Sedimentation Control Ordinance:"If the person financially responsible
is not a resident of North Carolina,a North Carolina agent must be designated in the statement for the purpose of receiving notice of
compliance or non-compliance with the plan,the Act,this ordinance,or rules or orders adopted or issued pursuant to this ordinance."
The person noted below is the designated North Carolina agent and is duly authorized by the financially responsible person to accept
and convey correspondence regarding the aforementioned project.
Name of Agent:
Mailing Address:
E-mail address:
Telephone: Cell: Fax:
Signature: Date:
E. Ccrnfic.krwn
I,the undersigned,attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible party,responsible for the construction activities and maintenance of the site until ownership is completed for the
above referenced project.I acknowledge receipt of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and have thereby been advised of the requirements therein as well as the penalties and resources available to the County in
the event of violation of the Ordinance.The above information is true and correct to the best of my knowledge and belief and was
provided by me while under o
Name: Ken Jackson Title: Manager
Signature: Date: /Z7/z�
I, k..9 lfi .�i ertn2 Z a Notary Public for the County of y�lf t'.%eO mb-t-
State of 14 01+V'! [ iA 1-0 i ,hereby certify that t tl ' tC ICStrf} personally
appeared before me this day and under oath acknowledged that the above form was executed by him and is correct to the best of his
knowledge and belief.
Witrte.. n day of 1 J\.V4&I '.\ 20 z .
•
NOTARY PUBLIC Now II /(�j`
BUNCOMBE 5`' '
NORTH CAROLINA My Commission Expires !&G. 2, LOI-1
�t.l XPIRI:ti nit." -
OF�CQ eSYS�r e Pemat No _ Check No.
U Date Paid Received by Date Issued
The County ofBuncomhe does not discriminate on the basis ofdisability in the admission or access to,or treatment or employment in,
its programs or activities.Requests for appropriate auxiliary aids and services,when necessary to offer a person with a disability ern
equal opportunity to participate in or enjoy the benefits of County services,programs, or activities, may be made by contacting
Buncombe County Erosion Control,[phone]. Buncombe County s TDD number is(828)250-4001.

BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PLANNING & DEVELOPMENT OWNERSHIP FORM FORA
[phone]•[e-mail]
www.buncombecounty.orgiplanning STORMWATER PERMIT
INSTRUCTIONS:All sections must be completed.Section D must be CASE NUMBER
completed in the presence of a Notary Public. -
1. IAktin Propel-IN lutirrntaliuu
Project Name: Rolling Hills
PIN(Numbers): 9606-48-6826
Latitude: 35.5348 Longitude: -82.8837 Amount of fee enclosed:$15'750.00
Project Location-Highway/Street:Un-addressed Queen Rd
Proposed Use: 8 Single Family Residence o Multi-Family o Vacation Rental o Commercial/Industrial o Other
Proposed Disturbed Area(Include offsite borrow and waste areas): 30 acre(s)
LI. .\ppJic;uu (,ntuaiI Iofor ..ul III
Name of Applicant: Queen Road Development Group,LLC State of Business Registration(if applicable): NC
Applicant's Point of Contact(for official correspondence):Ken Jackson
Mailing Address: P.O Box 1157 Arden,NC 28704
Street address: 3 Walden Ridge Drive,Suite 300 Asheville,NC 28803
E-mail address: [e-mail]
Telephone:[phone] Cell: Fax:
C. I.aurlmvnr•r(s)of Rccc,rd
Name of Landowner(s)of Record: C A WILLIS,JR.
Mailing Address: 2858 GREEN RIVER RD,ZIRCONIA,NC,28790
Recorded in Deed Book No: 5517/1706 page: 0234/0002
Name of Landowners)of Record:ANDERSON JOINT TRUST
Mailing Address: 2858 GREEN RIVER RD,ZIRCONIA,NC,28790
Recorded in Deed Book No: 5517/1706 Page: 0234/0002
Note:If applicant is not landowner of recortt provide executed Buncombe County Stormwater Agent Authorization Form
1). Cu ilicathol
I,the undersigned,attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible party,responsible for the installation,operation,and maintenance of the stormwater controls until ownership
is conveyed for the above referenced project.I acknowledge receipt of a copy of the County of Buncombe Stormwater Management
Ordinance and have thereby been advised of the requirements therein as well as the penalties and resources available to the County
in the event of violation of the Ordinance.The above information is true and correct to the best of my knowledge and belief and
was provided by me while under oath.
Financially Responsible Party: Q es Road Deve nt Group,LLC
Signature: Date: l f/ r /a y
Name: Ken Jackson Title: Manager
I, � ,^',l(l C3;��,Y ixe-n QZ- ,a Notary Public for the County of 111• �
L C ever03 -
State of iVtt�h L—Cc YG 1 r, n(4-- hereby certify that lLL rl 6.-cIc-36l� personally
appeared before me this day and under oath acknowledged that the above form was executed by him and is correct to the best of his
knowledge and belief.
Witness my hand and seal,this V ,_st^ ,20 2 4
$HEIIA JIMENEZ Notary (_ :�icJ v te.-es,�
NOTARY PUBLIC `�
BUNCOMBE My Commission Expires' G ) Z V C °�
NORTH CAROLINA
MY COMMISSION EXPIRES
OFFICE Review Fee S Permn No Check No
USE Date Paid Received by_ Date Issued
The County ofBuncomhe does not discriminate on the basis of disability in the admission or access to,or treatment or employment in,
its programs or activities.Requests for appropriate auxiliary aids and services,when necessary to offer a person with a disability an
equal opportunity to participate in or enjoy the benefits of County.services,programs, or activities, may be made by contacting
Buncombe County Erosion Control,[phone]. Buncombe County's TDD nunther is(821?)250-4001.

0 BUNCOMBE COUNTY FINANCIAL RESPONSIBILITY/
PLANNING & DEVELOPMENT OWNERSHIP FORM FOR AN
(826)[e-mail] EROSION CONTROL PERMIT
www.bu nctlmbecounty.orglplan n#ng
INSTRUCTIONS:All sections must be completed.Section E must be CASE NUMBER:
completed in the presence of a Notary Public.
A. l- kting I'roperl\ Inlin'maliun
PIN(Numbers): 9606-48-6826 Project Name; Rolling Hills
Latitude: 35'5348 Longitude: "82•6837 Amount of fee enclosed:S 15,750,00
Project Location-Highway/Street:Urn addressed Queen Rd
Proposed Use: a Single Family Residence ❑Multi-Family o Vacation Rental ❑Commercial/Industrial/Other o Other
Proposed Disturbed Area(Include offsite borrow and waste areas): 30 acre(s)
B. Contact Information noon(iatly Responsible Pcreun
Section 26-228(b)of the Buncombe County Soil Erosion and Sedimentation Control Ordinance: "Erosion control plans shall be
accompanied by a notarized statement of financial responsibility and ownership".This statement shall be signed by the person
financially responsible for the land disturbing activity or his attorney in fact.The undersigned states that he/she is the person
financially responsible for land disturbing activity described in this application and acknowledges receipt of a copy of the County of
Buncombe Soil Erosion and Sedimentation Control Ordinance and that he/she has thereby been advised of the requirements therein as
well as the penalties and resources available to the County in the event of violation of the Ordinance,including revocation of the Land
Disturbing Permit and all building permits issued in connection with the project covered by the application.
Name of Business: Queen Road Development Group,LLC Name of Applicant:Ken Jackson
Mailing Address: P.O Box 1157 Arden,NC 28704
Street address: 3 Walden Ridge Drive,Suite 300 Asheville,NC 28803
E-mail address: [e-mail]
Telephone:[phone] Cell: Fax:
C. Landowner(s)of Record
Name of Landowner(s)of Record: C A MUS Ir A!DERSON.10KT TRl1ST
Mailing Address: 2858 GREEN RIVER RD,ZIRCONIA,NC,28700
Recorded in Deed Book No: 5517/1706 page: 0234/0002
I), C:onfact Information North Caroliuil Agent (l1:Iij //,.rhlr) .
Section 26-228(b)of the Buncombe County Soil Erosion and Sedimentation Control Ordinance:"If the person financially responsible
is not a resident of North Carolina,a North Carolina agent must be designated in the statement for the purpose of receiving notice of
compliance or non-compliance with the plan,the Act,this ordinance,or rules or orders adopted or issued pursuant to this ordinance."
The person noted below is the designated North Carolina agent and is duly authorized by the financially responsible person to accept
and convey correspondence regarding the aforementioned project.
Name of Agent:
Mailing Address:
E-mail address:
Telephone: Cell: Fax:
Signature: Date:
I . Crrtitiratinn
1,the undersigned,attest that I am the financially responsible party or an authorized representative with signatory authority for the
financially responsible party,responsible for the construction activities and maintenance of the site until ownership is completed for the
above referenced project.I acknowledge receipt of a copy of the County of Buncombe Soil Erosion and Sedimentation Control
Ordinance and have thereby been advised of the requirements therein as well as the penalties and resources available to the County in
the event of violation of the Ordinance.The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath.
Name: Ken Jackson Title: Manager
Signature: _ Date: /V7/Z 7�/
i,t.e A t,..1 A. ,a Notary Public for the County of ,I3i t."E,C'�ly- - ,
1 r
State of QM3'1 Ll)utC 4i.c .-., hereby certify that W(ti'V. . personally
appeared be re me this day and under oath acknowledged that the above form as executed by him and is correct to the best of his
knowledge and belief.
Wimrss my handand teat ay�sf �\11..7 L1'Y...165.>.. ,20 2,4
SHEILA JI E •
NOTARY PUBLIC Notary A i:Jo✓ 9.(51/16L-Llji-k6
BUNCOMBE My Commission Expires �YVIC.�tc 2 Lt;"Z"'I
NORTHsARO►INA
VOMMISSPOITEX191RES MAY 02,2027 Permit No Cheek No
Date Paid. Received by. Date Issued
The County of Buncombe does not discriminate on the basis of disability in the admission or access to,or treatment or employment in,
its programs or activities'.Requests for appropriate auxiliary aids and services,when necessary to offer a person with a disability an
equal opportunity to participate in or enjoy the benefits of County services,programs, or activities, may be made by contacting
Buncombe County Erosion Control,[phone]. Buncombe County's TDD number is(828)250-4001.

SR 3447 STATE OF NORTH CAROLINA
ROUTE (Queen Rd) PROJECT Rolling Hills COUNTY OF evncompa
DEPARTMENT OF TRANSPORTATION THREE PARTY RIGHT OF WAY
-AND- ENCROACHMENT AGREEMENT ON
Oman Road Development Group,LLG PRIMARY AND SECONDARY SYSTEM
P.O Box 1157 Arden,NC 25704
-AND-
City of Asheville Water Resources
70 Court Plaza,Asheville,NC 28801
THIS AGREEMENT,made and entered into this the day of ,20 24 ,by and between the Department
of Transportation, party of the first part;and Queen Road Development Group,LLC
party of the second part;and City of Asheville Water Resources
party of the third part,
WITNESSETH
THAT WHEREAS,the party of the second part desires to encroach on the right of way of the public road designated as
Route(s) SR 3447(Queen Rd) ,located approximately 720 LF East of the intersection of Carrion in and
Queen Rd.
with the construction and/or erection Of: approximately 51LF of 6'DIP water main,(2)two 6'gate valves,and associated appurtenances.
WHEREAS,it is to the material advantage of the party of the second part to effect this encroachment,and the party of
the first part in the exercise of authority conferred upon it by statute, is willing to permit the encroachment within the limits of the
right of way as indicated,subject to the conditions of this agreement;
NOW,THEREFORE,IT IS AGREED that the party of the first part hereby grants to the party of the second part the right
and privilege to make this encroachment as shown on attached plan sheet(s),specifications and special provisions which are
made a part hereof upon the following conditions,to wit:
That the installation,operation,and maintenance of the above described facility wilt be accomplished in accordance with the party of
the first part's latest UTILITIES ACCOMMODATIONS MANUAL and such revisions and amendments thereto as may he in effect at the
date of this agreement. Information as to these policies and procedures may be obtained from the Division Engineer or State Utilities
Manager of the party of the first part.
That the said party of the second part binds and obligates himself to install and maintain the encroaching facility in such safe and proper
condition that ft will not interfere with or endanger travel upon said highway,nor obstruct nor interfere with the proper maintenance
thereof,to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways and structures
necessary due to installation and existence of the facilities of the party of the second part,and if at any time the party of the first part shall
require the removal of or changes in the location of the said facilities,that the said party of the second part binds himself,his successors
and assigns,to promptly remove or alter the said facilities,In order to conform to the said requirement,without any cost to the party of the
first part.
That the party of the second part agrees to provide during construction and any subsequent maintenance proper signs,signal lights,
flagmen and other warning devices for the protection of traffic In conformance with the latest Manual on Uniform Traffic Control Devices
for Streets and Highways and Amendments or Supplements thereto. Information as to the above rules and regulations may be obtained
from the Division Engineer of the party of the first.
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages and
claims for damage that may arise by reason of the Installation and maintenance of this encroachment.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of the
Division Engineer of the party of the first part. The party of the second part agrees to exercise every reasonable precaution during
construction and maintenance to prevent eroding of soil;silting or pollution of rivers,streams,lakes,reservoirs,other water
Impoundments,ground surfaces or other property;or pollution of the air. There shall be compliance with amicable rules and regulations
of the North Carolina Division of Environmental Management,North Carolina Sedimentation Control Commission,and with ordinances
and regulations of various counties,municipalities and other official agencies relating to pollution prevention and control. When any
Installation or maintenance operation disturbs the ground surface and existing ground cover,the party of the second part agrees to
remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division Engineer of the party of the
first part.
That the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary by the
Division Engineer of the party of the first part.
That the party of the second part agrees to have available at the construction site,at all times during construction,a copy of this
agreement showing evidence of approval by the party of the first part. The party of the first pert reserves the right to stop all work unless
evidence of approval can be shown.
Provided the work contained In this agreement is being performed on a completed highway open to traffic;the party of the second part
agrees to give written notice to the Division Engineer of the party of the first part when all work contained herein has been completed.
Unless specifically requested by the party of the first part,written notice of completion of work on highway projects under construction will
not be required.
That in the case of noncompliance with the terms of this agreement by the party of the second part,the party of the first part reserves
the right to stop all work until the facility has been brought into compliance or removed from the right of way at no cost to the party of the
first part.
That it is agreed by both parties that this agreement shall become void if actual construction of the work contemplated herein is not
begun within one(1)year from the date of authorization by the party of the first part unless written waiver is secured by the party of the
second part from the party of the first part.
FORM RAN 16.6
Rev.February 2021

During the performance of this contract,the second party,for itself,its assignees and successors in interest(hereinafter referred to as
the'contractor'),agrees as follows:
a. Compliance with Regulations: The contractor shall comply with the Regulations relative to nondiscrimination in Federally-
assisted programs of the U.S.Department of Transportation,Title 49,Code of Federal Regulations,Part 21,as they may be
amended from time to time,(hereinafter referred to as the Regulations),which are herein Incorporated by reference and
made a part of this contract.
b. Nondiscrimination: The contractor,with regard to the work performed by it during the contract,shall not discriminate on the
grounds of race,color,or national origin in the selection and retention of subcontractors,including procurements of materials
and leases of equipment. The contractor shall not participate either directly or indirectly in the discrimination prohibited by
Section 21,5 of the Regulations,including employment practices when the contract covers a program set forth in Appendix 9
of the Regulations.
c. Solicitations for Subcontracts,including Procurements of Materials and Equipment: in all solicitations either by competitive
bidding or negotiation made by the contractor for work to be performed under a subcontract,Including procurements of
materials or leases of equipment,each potential subcontractor or suppler shall be notified by the contractor of the
contractor's obligations under this contract and the Regulations relative to nondiscrimination on the grounds of race,color,or
national origin.
d. Information and Reports: The Contractor shall provide all information and reports required by the Regulations,or directives
issued pursuant thereto,and shall permit amass to its books,records,accounts,other sources of information,and Its
facilities as may be determined by the Department of Transportation or the Federal Highway Administration to be pertinent
to ascertain compliance with such Regulations or directives. Where any information required of a contractor is in the
exclusive possession of another who falls or refuses to furnish this information,the contractor shall so certify to the
Department of Transportation,or the Federal Highway Administration as appropriate,and shall set forth what efforts it has
made to obtain the information.
e. Sanctions for Noncompliance: In the event of the contractor's noncompliance with the nondiscrimination provisions of this
contract,the Department of Transportation shall impose such contract sanctions as it or the Federal Highway Administration
may determine to be appropriate,Including,but not limited to,
(1) withholding of payments to the contractor under the contract until the contractor complies,and/or
(2) cancellation,termination or suspension of the contract,in whole or in part.
f. Incorporation of Provisions: The contractor shall Include the provisions of paragraphs"a'through"f'in every subcontract,
including procurements of materials and leases of equipment,unless exempt by the Regulations,or directives issued
pursuant thereto. The contractor shall take such action with respect to any subcontract or procurement as the Department
of Transportation or the Federal Highway Administration may direct as a means of enforcing such provisions Including
sanctions for noncompliance: Provided,however,that,In the event a contractor becomes Involved in,or is threatened with,
litigation with a subcontractor or supplier as a result of such direction,the contractor may request the Department of
Transportation to enter into such litigation to protect the interests of the State,and,in addition,the contractor may request
the United States to enter into such litigation to protect the interests of the United States.
That when title to the subject that constitutes the aforesaid encroachment passes from the party of the second part
and vests in the party of the third part,the party of the third part agrees to assume all responsibilities and rights and to
perform all obligations as agreed to herein by the party of the second part.
R/W(166):Party of the Second Part certifies that this agreement is true and accurate copy of the form
RAW(166)incorporating all revisions to date.
IN WITNESS WHEREOF,each of the parties to this agreement has caused the same to be executed the day and
year first above written.
DEPARTMENT OF TRANSPORTATION
BY:
0 E EER
WITNESS:
r k
fri: 7;1
t £(.. !'fi. _ fits
Ken Jacks (Mann.-r)
Queen Road`Dment Group, LLC
P.O Box 1157 Arden, NC 28704
WITNESS: Second Party
David Melton (Utilities Director)
City of Asheville Water Resources
70 Court Plaza,Asheville, NC 28801
Third Party

OWNER'S AGREEMENT
PROJECT NAME: Rolling Hills
PROJECT LOCATION: Un-addressed Queen Rd
MSD PROJECT#: 2023244
ALLOCATION#: 2023244
PIN#: 9606-48-6826
NOTE: This agreement must be executed and returned to MSD as part of the plan
submittal package. Plan approval will not be issued until a fully executed agreement is on
file with the Planning and Development/Engineering department as part of the project
file. Copies of all correspondence will be forward to the party signing this agreement.
I Ken Jackson of Queen Road Development Group.LLC, hereby certify that I am the project owner and the party
contractually obligated for all costs associated with installation of the sewer system. This
includes the acquisition of any and all on-site and off-site sewer easements that may be
required and all other required documentation to complete sewer system transfer to MSD.
Construction of and documentation for said sewer system will be provided in accordance
with prevailing MSD standards and specifications for developer constructed sewer
systems. Issuance of building permits for this project will require evidence of approval
by MSD. A certificate of occupancy will not be issued until the following MSD
requirements have been satisfied.
1. As-built drawings
2. Easement/System transfer documents
3. Engineer's certification
4. Contractor's certification
5. MSD inspection approval
By my signature below, I acknowledge and agree to the terms outlined in this Owner's
Agreement.
This the 74 day of LOveri-,h4r , 20 Z4" .
Signature of owner: 7‘. SIGN NM,
Project Owner Name: Ken Jackson of Queen Road Development Group,LLC
Address: P.O Box 1157
Arden,NC 28704
Telephone: [phone]
Fax:

APPLICATION FOR NON-DISCHARGE PERMIT
GRAVITY SEWER SYSTEM EXTENSION
METROPOLITAN SEWERAGE DISTRICT OF BUNCOMBE COUNTY,NORTH CAROLINA
Project Name Rolling Hills
MSD Project Number 2023244
Project Type: [ ' New Construction ❑ Relocation El Modification of Permit
Wastewater Allocation Approval Number 2023244 Approved G.P.D. 30,000
Wastewater Treatment Plant receiving wastewater:
121 Metropolitan Sewerage District Of Buncombe County,North Carolina (NC0024911)
Nature of wastewater 100 %Domestic %Industrial
%Commercial %Other
Origin of wastewater 0 Subdivision ❑Commercial ❑School
❑Apartments/Condo(s) ❑Industrial ❑Other
List any parameter and it's concentration that will be greater than normal domestic levels:
If wastewater is non-domestic,describe level of pretreatment:
If a pretreatment permit is required,has one been issued? ❑YES g NO
Has Engineer determined N.C.D.W.Q.and M.S.D.minimum design standards are met by this project? [gYES ❑NO
Civil Design Concepts: 168 Patton Avenue,Asheville,NC 28801
Complete name and address of Engineering Design Firm:
Telephone 828 - 252 _5388
Professional En-"ccr's n.eiiuiatiors:
Donald S.Penson ,attest this application for Rolling Hills
has been reviewed by me and is accurate and complete to the best of my knowledge. I further attest to the
best of my knowledge the proposed design has been prepared in accordance with the applicable regulations. Although certain
portions of this submittal package may have been developed by other professionals,inclusion of these materials under my
signature and seal signifies I have reviewed this material and have judged it all to be consistent with the proposed design.
North Carolina Professional Engineer's Seal,Signature,and Date:
Owner's Name(print) Ken J: ks/ f Q i• Road`i -lopmcnt Group,LLC
Owner's signature: �// /#� Date: s�ro [
MS I ill accep wne ship of this system upon acceptance by the MSD Board of Directors
SEE http://www.madbc.org FOR CURREN . ES. Complete owner's agreement on back side
Rev.081611