NCC217023_FRO Submitted_20211220

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. SCM - Precast Site
1. Project Name
2. Location of land -disturbing activity: County Henderson City or Township Fletcher
Highway/Street 2" Old Hendersonville Road Latitude 35.408078 Longitude-82.507814
3. Approximate date land -disturbing activity will commence: December 17, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 800.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jason Conner
E-mail Address [e-mail]
Telephone [phone]
cell # 828-712--9009 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BV Hedrick Gravel and Sand 828-686-3844 828-686-3820
Name
Telephone Fax Number
PO Box 425
842 Old US Hwy 70 W
Current Mailing Address
Current Street Address
Swannanao NC
28778 Black Mtn NC 28711
City State
Zip City State Zip
10. Deed Book No.996
Page No.276 Provide the
a copy of 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.
BV Hedrick Gravel and
Sand [e-mail]
Name
E-mail Address
PO Box 425
[e-mail]
Current Mailing Address
Current Street Address
Swannanoa NC
28778 Black Mtn NC 28711
City State
Zip City State Zip
Telephone[phone]
_....... Fax Number 828--686-3820

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
Jason Conner VP - Land Managment
Type or print name Title or Authority
12µ6-2021
Signature Date
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1, A rA Volvo , a Notary Public of the County of 2url(zm6p,.
State of North Carolina, hereby certify that Jaw G her appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and no I seal, this
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