HomeMy WebLinkAboutNCC230463_FRO Submitted_20230315FINANCIAL 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 Lake James Boat & RV
2. Location of land -disturbing activity: County Burke City or Township Linville
Highway/Street 4147 NC 126 Latitude(decimaldegrees)35.777 Long ltude(decimaidegrees)-81'836
3. Approximate date land -disturbing activity will commence: June 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.95
6. Amount of fee enclosed: $ 100.00 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lee Gragg
Phone: Office #
E-mail Address
Mobile # 828-443-1924
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Trelzo, L.L.C.
Name Phone: Office # Mobile #
301 Riverside Drive 301 Riverside Drive
Current Mailing Address Current Street Address
Morganton, NC 28655 Morganton, NC 28655
City State
10. Deed Book No. 2251
Zip City
Page No. 744
State
Zip
Provide a copy of the most current deed.
RECEIVED
OCT 2 S N-22
LAND QUAu1Y SECT101"
ASHEVIiLF
Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
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 the financially responsible party(ies).
Trelzo, L.L.C.
Company Name E-mail Address
301 Riverside Drive
Current Mailing Address
Morganton, NC 28655
City
Phone: Office #
State Zip
Current Street Address
City State Zip
Mobile # 828-443-1924
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:
Jonathan Lee Gragg
Name of Registered Agent
301 Riverside Drive
E-mail Address
301 Riverside Drive
Current Mailing Address Current Street Address
Morganton, NC 28655 Morganton, NC 28655
City State Zip City State Zip
Phone: Office # Mobile # 828-443-1924
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 -
fiPT 25 _2112
Current Mailing Address Current Street Address
LAND QUALITY 5LlMON
City State Zip City State Zip
Phone: Office # Mobile #
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.
Trelzo, L.L.C.
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.
Jonathan Lee Gragg
Type or print name
signature
----------------------- --------------------------------------
Manager/Registered Agent
Title or Authority
Date
I, �O a Notary Public of the County of T) U,V
State of North Carolina, hereby certify that I—k-Q I( appeared personally
before me this day and being duly sworn acknowledged that the above for s executed by him/her.
Witness my hand and notarial seal, this a4'r�-ay of _C`J-6kir _ �, 20 AD,
Sherry Young
{VOTARY PUBLIC Notary c_
e,, I Burke County, NC
My Commission Expires My commission expires �a— I q aor),3
j)C ?, .� 2022
i_ANID QUALITY SECTION'
ASHEUii_.LE