NCC220148_FRO Submitted_20220120

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 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. Hayesville New Retail Development
1. Project Name
2. Location of land -disturbing activity: County Clay City or Township Hayesville
Highway/Street Hwy 64 East Latitude 35"02'00.8"N Longitude 83"49'10.0"W
3. Approximate date land -disturbing activity will commence: 12/01 /2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.0
6. Amount of fee enclosed: $ 130.00 . 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 WTC of Hayesville - Jim Price E-mail Address [e-mail]
Telephone [phone] cell # [phone] N/A
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WTC of Hayesville - Jim Price [phone] NIA
Name Telephone Fax Number
2240 Sage Valley Drive 2240 Sage Valley Drive
Current Mailing Address Current Street Address
Graniteville SC 29829 Graniteville SC 29829
City State Zip City State Zip
10. Deed Book No, 283 Page No. 95 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.
WTC of Hayesville - Jim Price [e-mail]
Name
2240 Sage Valley Drive
Current Mailing Address
Graniteville Sc
City State
Telephone [phone]
E-mail Address
2240 Sage Valley Drive
Current Street Address
29829 Graniteville Sc
Zip City State
Fax Number NIA
29829
WE

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:
NIA
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:
Chip Goforth [e-mail]
Name of Registered Agent E-mail Address
2240 Sage Valley Drive 2240 Sage Valley Drive
Current Mailing Address Current Street Address
Graniteville SC 29829 Graniteville SC 29829
City State Zip City State Zip
Telephone [phone] Fax Number NIA
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.
C u r p C'Or,1,zTey�
WTC of Hayesville - 3ie�e A✓IC,��3c�.P
Type or print name
Signature
Title or Autho ity
Z
Date
I, y.Jon��►� � ter►% �- a Notary Public of the County ofke�
State of North Carolina, hereby certify that A,-nAS "Cti;p gie"ffi
appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this Z day of v Voy �8 Ae— , 20
Notary
Seal
v My commission expiresi��
0
Donna F. Humble
�, ' Notary Public, State of Soufh Carolina
'`►vty Commission Expires May 27, 2030

NORTH CAROLINA
A Department of the Secretary of State
CERTIFICATE OF AUTHORITY
I, ELAINE F. MARSHALL, Secretary of State of the State of North Carolina, do hereby
certify that
WTC OF HAYESVILLE, LLC
having filed on this date an application conforming to the requirements of the General
Statutes of North Carolina, a copy of which is hereto attached, is hereby granted
authority to transact business in the State ofNorth Carolina.
IN WITNESS WHEREOF, I have hereunto set
my hand and affixed my official seal at the City
of Raleigh, this 4th day of January, 2022.
Scan to verify online.
Document Id: C202200400502 Secretary of State
Verify this certificate online at https://www.sosnc.gov/verification