NCC232634_FRO Submitted_20230830

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name: EB-5937-Book Walk
2. Location of land-disturbing activity: County: Catawba City or Township: Hickory
Highway/Street 1st Street SW Latitude 35.718788 Longitude-81.338407
3. Approximate date land-disturbing activity will commence: Fall 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Greenway
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.90
6. Amount of fee enclosed: $195 The application fee of$65.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 9-acre application fee is$585).
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 Tori Golaszewski E-mail Address Tori.GolaszewskiCcr�kimlev-horn.com
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Hickory
Name Telephone Fax Number
PO Box 398 PO Box 398
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 3607 Page No. 0545-0548 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 company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
City of Hickory-Enctineerino Department [e-mail]
Name E-mail Address
PO Box 398 PO Box 398
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 Fax Number
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
corr ted information should there be any change in the information provided herein.
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Type int me Title or Authority
6-2,P-Z(
Signatur Date
I, Oj1/l,ST M1A-A O otary Public of the County of l47/1't&JLM
State of North Carolina, hereby certify that 1\WVI M( L 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 �,�(J'" uay of , 2021
CRYSTAL B MUNDY CA
NOTARY PUBLIC Notary
Catawba County
SealNorth Carolina It
My Commission Expires Li
22- My commission expires 1. ( 10Z 7.0 22-

9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Hickory
Name Telephone Fax Number
PO Box 398 PO Box 398
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2476 Page No. 1620 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mt. Pisgah African Methodist Episcopal Church
Name Telephone Fax Number
624 1 St St SW 624 1 St St SW
Current Mailing Address Current Street Address
Hickory NC 28602 Hickory NC 28602
City State Zip City State Zip
10. Deed Book No. 0986 Page No. 0703 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Walter Eugene Patterson, Sr
Name Telephone Fax Number
625 2"d Street Place SW 625 2"d Street Place SW
Current Mailing Address Current Street Address
Hickory NC 28602 Hickory NC 28602
City State Zip City State Zip
10. Deed Book No. 3567 Page No. 1548 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Dorothy G. Shuford and Vivian Brooks
Name Telephone Fax Number
31 Spring Street 31 Spring Street
Current Mailing Address Current Street Address
Brockton MA 02401 Brockton MA 02401
City State Zip City State Zip
10. Deed Book No. 1545 Page No. 0555 Provide a copy of the most current deed.

9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Hickory
Name Telephone Fax Number
PO Box 398 PO Box 398
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2476 Page No. 1620 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Hickory
Name Telephone Fax Number
PO Box 398 PO Box 398
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2476 Page No. 1620 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Audrey Carson
Name Telephone Fax Number
113 5"'Avenue SW 113 51h Avenue SW
Current Mailing Address Current Street Address
Hickory NC 28602 Hickory NC 28602
City State Zip City State Zip
10. Deed Book No. 1983 Page No. 1430 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Barbara Heur
Name Telephone Fax Number
448 1st Street SW 448 1st Street SW
Current Mailing Address Current Street Address
Hickory NC 28602 Hickory NC 28602
City State Zip City State Zip
10. Deed Book No. 3645 Page No. 0549 Provide a copy of the most current deed.

9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ivey Dula
Name Telephone Fax Number
444 1S' Street SW 444 1St Street SW
Current Mailing Address Current Street Address
Hickory NC 28602 Hickory NC 28602
City State Zip City State Zip
10. Deed Book No. 1097 Page No. 0207 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Clemente Leal and Rebeca Elizabeth Leal
Name Telephone Fax Number
436 1St Street SW 436 1st Street SW
Current Mailing Address Current Street Address
Hickory NC 28601 Hickory NC 28601
City State Zip City State Zip
10. Deed Book No. 3637 Page No. 1718 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Martha G. Wilson
Name Telephone Fax Number
428 1St Street SW 428 1S' Street SW
Current Mailing Address Current Street Address
Hickory NC 28602 Hickory NC 28602
City State Zip City State Zip
10. Deed Book No. 2275 Page No. 1289 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gussie Shuford Bost and Christine Shuford
Name Telephone Fax Number
Current Mailing Address — Current Street Address
Hickory NC Hickory NC
City State Zip City State Zip
10. Deed Book No. 0287 Page No. 0152 Provide a copy of the most current deed.

9. Landowner(s) of Record (attach accompanied page to list additional owners):
Friendship Baptist Church
Name Telephone Fax Number
PO Box 1883 PO Box 1883
Current Mailing Address Current Street Address
Hickory NC Hickory NC
City State Zip City State Zip
10. Deed Book No. 1242 Page No. 0034 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Morning Star First Baptist Church
Name Telephone Fax Number
126 4`h Avenue 126 4th Avenue
Current Mailing Address Current Street Address
Hickory NC 28602 Hickory NC 28602
City State Zip City State Zip
10. Deed Book No. 1952 Page No. 1462 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Inter-Faith Housing Development
Name Telephone Fax Number
PO Box 3547 PO Box 3547
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2090 Page No. 0205 Provide a copy of the most current deed.
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Charlette Patterson Gore, etc.
Name Telephone Fax Number
610 3� Street SE 610 3' Street SE
Current Mailing Address Current Street Address
Hickory NC 28602 Hickory NC 28602
City State Zip City State Zip
10. Deed Book No. 3505 Page No. 0625 Provide a copy of the most current deed.

9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Hickory
Name Telephone Fax Number
PO Box 398 PO Box 398
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 3174 Page No. 1640 Provide a copy of the most current deed.
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Herbert Allen Mitchell, Sr., etc.
Name Telephone Fax Number
PO Box PO Box
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 1518 Page No. 0127 Provide a copy of the most current deed.
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Family and Community Enrichment Development Center
Name Telephone Fax Number
PO Box 2931 PO Box 2931
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2115 Page No. 1490 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Family and Community Enrichment Development Center
Name Telephone Fax Number
PO Box 2931 PO Box 2931
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2125 Page No. 0661 Provide a copy of the most current deed.

10. Landowner(s) of Record (attach accompanied page to list additional owners):
Family and Community Enrichment Development Center
Name Telephone Fax Number
PO Box 2931 PO Box 2931
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2125 Page No. 0661 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Herbert Allen Mitchell, Sr., etc.
Name Telephone Fax Number
PO Box 1848 PO Box 1848
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2549 Page No. 0650 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Herbert Allen Mitchell, Sr., etc.
Name Telephone Fax Number
PO Box 1848 PO Box 1848
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2539 Page No. 0727 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Monro Muffler Brake
Name Telephone Fax Number
200 Holleder Parkway 200 Holleder Parkway
Current Mailing Address Current Street Address
Rochester NY 14615 Rochester NY 14615
City State Zip City State Zip
10. Deed Book No. 3361 Page No. 1090 Provide a copy of the most current deed.

9. Landowner(s) of Record (attach accompanied page to list additional owners):
Monro Muffler Brake
Name Telephone Fax Number
200 Holleder Parkway 200 Holleder Parkway
Current Mailing Address Current Street Address
Rochester NY 14615 Rochester NY 14615
City State Zip City State Zip
10. Deed Book No. 3361 Page No. 1093 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Monro Muffler Brake
Name Telephone Fax Number
200 Holleder Parkway 200 Holleder Parkway
Current Mailing Address Current Street Address
Rochester NY 14615 Rochester NY 14615
City State Zip City State Zip
10. Deed Book No. 3361 Page No. 1151 Provide a copy of the most current deed.
9. Landowner(s) of Record (attach accompanied page to list additional owners):
John D. Clark
Name Telephone Fax Number
PO Box 2108 PO Box 2108
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2021 Page No. 1814 Provide a copy of the most current deed.
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Center Crossing Limited Partnership
Name Telephone Fax Number
500 S. Font Street, 10th Floor 500 S. Font Street, 10th Floor
Current Mailing Address Current Street Address
Columbus OH 43215 Columbus OH 43215
City State Zip City State Zip
10. Deed Book No. 3576 Page No. 0777 Provide a copy of the most current deed.

9. Landowner(s) of Record (attach accompanied page to list additional owners):
Woodland Village
Name Telephone Fax Number
1301 N. Center Street 1301 N. Center Street
Current Mailing Address Current Street Address
Hickory NC 28601 Hickory NC 28601
City State Zip City State Zip
10. Deed Book No. 3363 Page No. 1693 Provide a copy of the most current deed.