NCC222733_FRO Submitted_20220801

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 N/A in the blank.)
Part A. ALEXANDER COUNTY SHELL BUILDING
1. Project Name
2. Location of land -disturbing activity: County ALEXANDER
SR-1584 35 911725
City or Township H I D D E N ITE
Highway/Street Latitude Longitude
3. Approximate date land -disturbing activity will commence:
OCTOBER 2019
-81.119511
4. Purpose of development (residential, commercial, industrial, institutional, etc.): INDUSTRIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 23
6. Amount of fee enclosed: $ 1,495.00 . 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 David Icenhour E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ALEXANDER COUNTY ECONOMIC DEVELOPMENT
Name Telephone Fax Number
621 LILEDOUN RD NC HWY 90 E
Current Mailing Address Current Street Address
TAYLORSVILLE, NC 28681 TAYLORSVILLE, NC 28681
City State Zip City Slate zip
10. Deed Book No. 0534 Page No. 1720 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.
David Icenhour [e-mail]
Name
621 Liledoun Road
Current Mailing Address
Taylorsville, NC, 28681
City
E-mail Address
119 NC HWY 16 N - Suite A
Current Street Address
Taylorsville, NC, 28681
State zip City
Telephone [phone] Fax Number
State
0

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
Current Mailing Address
E-mail 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.
David Icenhour
Type or print name
Signature
Executive Director
Title or Authority
I -I � l
Date
M . �WJPS , a Notary Public of the County of,Awndir
State of North Carolina, hereby certify that. y-iA I Cerl do ur appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my aa�rj0Enair�yal seal, this 'day of , 20��
3P� M, s� .
NOT,'¢�- - n'
Not
BCIc MyV
mmission expires 3 )A09.1