NCC220295_FRO Submitted_20220118

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 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 Environment and Natural Resources. (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.
1. Project Name Dales Creek Restoration Site
2. Location of land -disturbing activity: Buncombe City or Township Leicester
Highway/Street— Green Valley Road Latitude 35.597815 N Longitude-82.744237 W
3. Approximate date land -disturbing activity will commence: 1 June 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): environmental restoration
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):!0.16 10.33 acres
6. Amount of fee enclosed: $0.00 ($715 Paid previously). The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Tim Morris E-mail Address tim.morris kci.com
Telephone [phone] Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Martin Morgan 828-712-9232
Name Telephone Fax Number
75 Morgan Branch Road
Current Mailing Address Current Street Address
Leicester NC 28748 _
City State Zip City State Zip
10. Deed Book No. 5608 Page No.1682 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
KCI Environmental Technoloules and Construction Inc tim morrisccD-kci.com
Name E-mail Address
4505 Falls of the Neuse Road, Suite 400
Current Mailing Address
Ralei h NC 27609
City State Zip
Same
Current Street Address
City
State
Telephone [phone] Fax Number_ 9( 19) 783-9266
Zip

2. (a) It the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
NIA
Name E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip City
Fax Number
State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certifflicate of Assumed Name. if the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
_CT Corporation
Name of Registered Agent
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone_866-925-9916.
[e-mail]
E-mail Address
same
Current Street Address
City
Fax Number NA
State Zip
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.
Tim Morris Assistant Secrets
Type or print name Title or Authority
91
Signature Date
a Notary Public of the County of
State of North Carolina, hereby certify that _ f -,= ." appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my2ZO
"'6'jr8� al seal, this 7 day of � , 20 /
'tAR,bo�9
3' v Notary
Aal r, 12/
My commission expires O-Z 3 2o'Z C