NCC230483_FRO Submitted_20230223

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Hwy 64 Retail Development
2. Location of land -disturbing activity: County Davie City or Township Mocksville
Hwy 64 35.884087 80.511593
Highway/Street Y Latitude(d.,iwid�grsss� Lon gitude(denlmaldegmn)
3. Approximate date land -disturbing activity will commence: Feb 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Commercial Retail
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.60 acres
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 2 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Carl Carney E-mail Address [e-mail]
Phone: Office #
Mobile it 336-399-2905
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BCM Associates, LLC 336-399-2905
Name Phone: Office # Mobile #
PO Box 1724
152 E. Kinderton Way #200
Current Mailing Address Current Street Address
Clemmons NC 27012 Bermuda Run NC 27006
City
State
10. Deed Book No. 639 Page
Zip City
to, 768
State
Zip
Provide a copy of the most current doed.

Part B.
1. Company(ies) who are financially responsible for the [and -disturbing activity (Provide a comprehensive fist
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as tho financially responsible pady(ies).
BCM Associates, LLC [e-mail]
Company Name E-mail Address
PO Box 1724 152 E. Kinderton Way #200
Current Mailing Address Current Street Address
Clemmons NC 27012 Bermuda Run NC 27006
City State Zip City State Zip
Phone: Office # Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Carl Carney
Name of Registered Agent
PO Box 1724
Current Mailing Address
Clemmon NC 27012
City State Zip
Phone: Office #
[e-mail]
E-mail Address
152 E. Kinderton Way #200
Current Street Address
Bermuda Run NC 27006
City State Zip
Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North 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: Office # Mobile It
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As, If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Carl Carney
Type or p ' ame
Manager
Title or Authority
3ANIAM ft1 6 213
Date
.........._......----_----...._..----..______________________________________.
I, :d&A � 6 P n , a Notary Public of the County of
State of North Carolina, hereby certify that � � V [,_lQ-1 lycoo f- appeared personally
hat abov before me this day and being duly sworn acknowledged tthe e form was executed by himlher.
Witness my hand and notarial seal, this t t7*4day of V AAJQA , 20 r3
Al, Notary
NINA YORK
j fARY PUBLIC
A K!N COUNTY My commission expires
NORTH CLUOLINA p Q
L
y COf1 MY SSIor) EXnirBs May 2.2023