NCC223697_FRO Submitted_20221031

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
No person may initiate any land -disturbing activity on one or more acres as covered by the Actbefore 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 in not applicable or the e-mail address or phone
number iounavailable, place N/A inthe b|ank.)
Project Name Transylvania County EMS Base
2. Location ofland-disturbing activity: City orTownship Bnevmrd
Highway/Street LmUtude(demmmdegrev LongitUde(demm degrees) -82.70726
3. Approximate date land -disturbing activity will commence: 1/1/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed oruncovered (including off -site borrow and waste aroao)
G. Amount offee enclosed The Express Permitting application fee isadual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee ima fixed $2.OUO.0O(Examp|n:O.1U-acreapplication fee io$2.QUU). Checks
should beaddressed tnNCDE(].
Has onerosion and sediment control plan been filed? Yes El Enclosed X No O
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David McNeill E-mail Address [e-mail]
Phone: Offiva# 828884-3108 Mobile #
S. Landowner(n)nfRecord (attach accompanied page tulist additional owner ):
Transylvania County
Name
152 Public Safety Way
Current Mailing Address
City State Zip
828-884-3108
Phone: Office# Mobile #
152 Public Safety Way
Current Street Address
Brevard
City
0.
10. Deed Book No. Page Provide acopy ofthe most current deed.

1. Compony(iem)who are financially responsible for the land -disturbing acUvKy(Pnovideaoompnehensivmlist
of all responsible parties onaccompanied page.) landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Transylvania County
Company Name
152 Public Safety Way
Current Mailing Address
City State Zip
E-mail Address
david
152PubUt Safety Way
Current Street Address
City
Phone: Office# 828-884-8108 NYobi|e#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
thahandovvner's signed and dated written consent for the applicant hosubmit adraft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) Ifthe Financially Responsible Party isodomestic company registered onthe NCSecretary ofState
business registry, give name and street address of the Registered Agent:
Name ofRegistered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office# Mobile #
Name ofIndividual |oContact (if Registered Agent isacompany)
(b) If the Financially Responsible Party isnot aresident ofNorth Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Offioe# Mnbike#
Name ofIndividual toContact (if Registered Agent ioacompany)
(o)Ifthe Financially Responsible Party iaengaging inbusiness under anassumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party in an individual, General

Partnership, mother company not registered and doing business under anassumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d)Korder to facilitate Express Permitting, disnecessary toboable to contact the engineer orother
consultant who can assist inproviding any necessary information regarding the plan and its preparation:
High Country Engineering, PC
Engineering firm orother consultant
Michael R. Goforth, PE
Individual contact person (type or print)
E-mail Address
828-2304511
Phone: Office#
The above information kstrue and correct tothe best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if anindividuu|ia\
or his attnrney-in-fa(t, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected information should there be any change in the information provided herein.
Type or print name —
Milt, �­re --- -- ­*
Title or Authorifty 1j
[Y. aNotary Public oftheCountvpf
GLataof��o�hCano|ina.herebvoe�k/th appeared personally
before me this day and being duly sworn acknowledged that 655 above form was executed by him/her.
Witness myhand and notarial seal, thh; ck oyof
My commission expires