NCC230688_FRO Submitted_20230315

Check if this project is ARPA-funded D
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity an one or more acres as covered by the Act, including any
activity under a common plan of development of this size as cowered by the NCGO1 permit, before this form
and an acceptable erasion and sedimentation control plan have been completed and approved by the Land
duality Section, N.C. Department of Environmental Quality_ Submit the completed form to the approprka#e
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
'I. Project [Name De Cesare
V this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Wafer Infrastructure (DWI).
2. Location of land --disturbing activity: Cauniy I redel I City v�- TownshiP.-
148Troutman
Highway/Street Maple View Dr Latitude(decimai tsegrees) LOngItudE(decimai degrees)
3. Approximate date land -disturbing activity will commence: 03/13/2023
4. Purpose of development (residential, commercEal, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.25 acresoff-site
6. Amount of fey enclosed: $200w00 . The application fie of $100.0D per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application flee is $900)_
Checks should be addressed to NCDEQ.
i. H2S2n erosion and sediment control plan been filed? Yes m Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name 0scar Koehler Jr E-mail Address okoehlerhomes@aol com
10.
Phone: Office# 704-528- 1235 Mob;,e # 704-309-0227
Landowner(s) of Record (attach accompanied page to list additional owners). -
Howard De Cesare
Name
107 Elba Dr
Current Mailing Address
Mooresville NC 28115
Phone: Office #
516-383-2100
current Street Address
Same
516-383-2100
Mobile #
City State Zip City 5fiaie Zip
Deed Book Na. 0 2 70 1 Page Na. 1758 Provide a copy of the most current deed.

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. ) 1f the company is a sole proprietorship or if the landowner(s) is
an individua!(s), the name(s) of the owner(s) maybe listed as the financially responsible party(ies)_
Koehler Homes Inc
Company Name
167 Maple View Dr
Current Mailing Address
Troutman NC 28166
City State Zip
Phone: Office# 704-528-1235
okoehlerhomes,'"O�k��aol.com
E-mail Address
Current Street Address
City State Zip
twobile # 704-309-0227
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 hand 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.
Oscar Koehler Jr
Name of Registered Agent
167 Maple View Dr
Current Mailing Address
Troutman NC 28166
City
State
Phone: Office# 704-528-1235
Oscar Koehler Jr
Zip
[e-mail]
E-mail Address
Current Street Address
City
Mob'fle # 704-309-0227
Name of Individual to Contact cif Registered Agent is a Company)
State Zip
(b) If the Financially Responsibly
Party
is not
a resident
of North Catalina, 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
Current Mailing Address
City State dip
Phone. Office
E-mail Address
Current Street Address
City
Mobile #
Name of Individual to Contact cif Registered Agent is a company)
State
Zip

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 SBA Name
The abase information is true and correct to the best of my knowledge2nd 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 here -in.
Oscar Koehler Jr
Type or min
Signatu
15
ame
President
Title or Authority
3/8/20
Date
�P=PW=PFffMM �Wdma iii iWawmm� i i i �ii �a r W Mm 1! wl iiii M M i Mil Ma Y Y��
AMY�Q �� �2a�-�L �C tv� .-. , a Notary Public of the County of
�Q--,del
State of North Carolina,, hereby certify that C)5Q00(_ I(� eV_�\ Or .37iz � appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this (�A . day of
MARIA J. WEATHERMAN
NOTARY PUBLIC
lraM County
= Lal North Carolina�
My Commission Expires
�r C%0% � 20 a3 -
Notary
My commission expires Ttjnc 3t-, r�oDsq

Continued from Items 9 & 70 in Part A of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page as needed to list a!1 landowners.
Landowner 2 of Record:
Howard De Cesare
Name
107 Elba Dr
Current Mailing Address
Mooresville NC 28115
City State Zip
Phone-, Office#
Current Street Address
516-383-2100
Mobile #
City State Zip
Died Book No. 02701 Pae No. 1758
g
Landowner 3 of Record:
Name
Current Mailing Address
City State Zip
Dees! Book No.
Landowner 4 of Record. -
Name
Current Mailing Address
Provide a cc of the most current deed.
Phone: Office #
Current Street Address
City
State
Mobile #
Zip
Page No. I Provide a copy of the most current deed.
City State Zip
Deed Book No -
Landowner 5 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State Zip
Page No. Provide a copy of the most current deed.
City State Zip
Phone: Office#
Current Street Address
City
State
Mobile #
Zip
deed Book Na. Page No. Provide a copy of the most current deed.

Continued from Item 9 in Park B of the Financial ResponsibilitylOwnership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties -
Company 2 Name
Current Mailing Address
City State dip
Phone: Off Ice #
Company 3 Name
Current Mailing Address
City State Zip
Phone- office #
Company 4 Name
Current Mailing Address
City State
Phone: Office #
Company 5 Name
Current Mailing Address
City
Phone: Office #
State
E-mail Address
Current Street Address
City
Mobile #
E-mail Address
Current Street Address
City
E-mail Address
Current Street Address
State
State
Zip
Zip City State Zip
Zip
Mobile #
E-mail Address
Current Street Address
City State Zip
Mobile #