NCC222986_FRO Submitted_20220916

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Naaft FINANCIAL RESPONSIBILITYIOWNERSHIP FORM 40W
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 Henderson County Site Development Department. (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.)
Sign the original form in BLUE INK.
Part A,
1, Project Name Blue Ridge Commerce Center
2
Location of land -disturbing activity: County Henderson
City Flat Rock
Highway/Street McMurray Road Latitude 35deg18'10"N Longitude 82deg24'30"W
Property Identification Number(s) PIN's 95-a8233f51-,-,g&88231-26:T,-�958$`F31657�g- 9588-23-5279
MBINED)
3. Approximate date land -disturbing activity will commence: June 27, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 53
8. Amount of fee enclosed: $ 16,100 . The application fee of $300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac = $2,900.00).
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 Adair Simpson E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ASHEVILLE INDUSTRIAL OWNER LLC 952
Name
Telephone
2000 REGENCY PARKWAY; SUITE 435
2000 REGENCY PARKWAY; SUITE 435
Current Mailing Address
Current Street Address
Cary NC 27518
Cary NC 27518
City State Zip
City State Zip
10. Deed Book No, Page No.
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 companyorfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
ASHEVILLE INDUSTRIAL OWNER LLC
[e-mail]
Name
E-mail Address
400 Water Street, suite 200
400 Water Street, Suite 200
Current Mailing Address
Current Street Address
Excelsior MN 55331
Excelsior MN 55331
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:
NIA
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(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
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.
Dave Scott
Type or print name
Signature
------------------------------------
Executive Vice President
Title or Authority
Date
`2 • 8' Za z -2-
I,yw°`'r5C' , a Notary Public of the County of flc �i�•:,
State of r nix e S6t'A hereby certify that D,, �( 5��-
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
t „ VERA T5CHIDA
eal NOTARY PUBLIC
MINNESOTA
r %lt' Commiss+orn Expires 113112026
9 day of -T-
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Notary
My commission expires Is Zo zG