NCC222487_FRO Submitted_20220712

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 N/A in the blank.)
Part A. 1Project NameOak Hill Community Park & Forest TRAILS
.
2. Location of land -disturbing activity: County Burke City or Township Quaker Meadows
Highway/street 820 NC Hwy 126 Latitude 35.7532-81.7465
Longitude
3. Approximate date land -disturbing activity will commence:April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.24 acres
6. Amount of fee enclosed: $ 900 + 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:
NameAndrew Kota E-mail Address [e-mail]
Telephone [phone] Cell # 828-403-7121 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Foothills Conservancy of NC, Inc. 828-437-9930
Name Telephone Fax Number
PO Box 3023 204 Avery Avenue
Current Mailing Address Current Street Address
Morganton NC 28680 Morganton NC 28680
City State Zip City State
Zip
10. Deed Book No. 2492 Page No. 475
g 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.
Foothills Conservancy of NC, Inc. [e-mail]
Name E-mail Address
PO Box 3023 204 Avery Avenue
Current Mailing Address Current Street Address
Morganton NC 28680 Morganton NC 28680
City State Zip City State Zip
Telephone [phone] Fax Number

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 Current Street Address
City State Zip City
State Zip
Telephone 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
Current Mailing Address
City State
Telephone.
E-mail Address
Current Street Address
Zip City
Fax Number
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.
Andrew Kota
Type or print nam
Signature
Executive Director
i itie or Authority
a�Z Z
Date
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I L)a d. a Notary Public of the County of U f Ice —
State of North Carolina, hereby certify that 7T/) (D[C Gy
personally before me this day and being duly sworn acknowledged that the above formeared was
executed by him.
Witness my hand and notarial seal, this p day of _ U 1� 20�
ANGELA C EDWARDS 0
Notary Public _Z4
Burk�l NorteS Jul ling 2026 ry
My CommissionExp' y My commission expires