NCC217083_FRO Submitted_20220105

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on '/ acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development. Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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.
Project Name__ Ingles #132 - Franklin, NC
2. Location of land -disturbing activity: County Macon City or Township Franklin
Highway/Street 4501 US 441 Bypass Latitude 35 deg 10' 54" N Longitude 83 deg 21 ` 20" W
3. Approximate date land -disturbing activity will commence: F 12/1/20
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): E18,57
6. Amount of fee enclosed: $ 3,010 The application fee of $100.0D per acre -riainidio Pp
P to #ho njpxt aaey is assessed without a ceiling amount (Example: a 1 acre-$100.00),
7. Has an erosion and sediment control plan been filed? Yes NoEnclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Preston Kendall E-mail AddressE [e-mail]
Telephone [phone] Cell # 828-768-3992 p Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ingles Markets, Incorporated 0 828-669-2941 © 828-669-3698
Name Telephone Fax Number
P.O. Box 6676 0 2913 US Hwy 70 W 0
Current Mailing Address Current Street Address
Asheville NC 28816 Black Mountain NC 287111
City State Zip City State Zip
10. Deed Book No. CRP X-36 Page No.E 1319-1324 Provide a copy of the most current deed.
Part B.
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.
Ingles Markets, Inc 0 [e-mail] (Randy Jameson)
Name E-mail Address
P.O. Box 6676 0 213 US Highway 70 W 0
Current Mailing Address Current Street Address
Asheville NC 28816 Black Mountain NC 28711
City State Zip City State Zip

Telephone [phone] Fax Number 828-669-3698
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
City State Zip
Telephone
Current Street Address
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 I 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.
Randy Jameson 0
Type or print name
Signature
17 VP of Real Estate 0
Title or Authority
12-3-2021
Date
a Notary Public of the County of
State of North Carolina, hereby certify that e.SQ2/L appeared
personally before me this day and being duly swoffi acknowledged that the above form was
executed by him.
Witness my `hand! 616 ioptarial seal, this[Mclay of 20
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�� !Votary Public
Henderson
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