NCC233674_FRO Submitted_20231213

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, including any
aciiviiy untie' d cuinnruii piaii of deveiopmeni ui Otis site as euvereu by iire NCGO i perrnii, uefue iiiis funs
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 N/A in the blank.)
Part A.
1. Project Name: Emberglow Outdoor Resort RV Expansion
`If this project involves American Rescue Plan Act(ARPA)funds,list the Project Name below under which
you applied for funding through the Division of Water Infrastructure(DWI).
Is Project ARPA Funded ARPA Project Name ARPA Project#
NO i I
2. Location of land-disturbing activity: County: Polk City or Township: Mill Spring
Highway/Street: Rock Spring Road (SR 1311) Latitude: 35.384500 Longitude -
82.129600
3. Approximate date land-disturbing activity will commence: 12/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1.80
6. Tile appiieaiiuii fee ui $i00.00 pet acre (iuunued up iu iite nexi acre) is assessed wiiiwui a ceiling
amount (Example: 8.10-acre application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes-Will be Mailed or Hand-Delivered
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Nance. Tin) iviurpity E-inaii Address. [e-mail]
Phone: [phone] Mobile: [phone]
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
Lake Lure Campground, LLC [e-mail] 1-(828)-625-2205 1-(704)-249-
8381
Physical Address Mailing Address
Street 1 City State Zip Street 1 City i State Zip
I95 Pinewood Mill Spring NC 28756 95 Pinewood Trail Mill Spring NC 28756
Trail

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 or if the landowner(s)is an individual(s),the
Primary Financially Responsible Party
Company Name ( Email { Business Phone I Mobile Phone
Lake Lure Campground, LLC ,[e-mail] , 1-(828)-625-2205 , 1-(704)-249-8381
Physical Address Mailing Address
Street 1 I City I State I Zia Street 1 I City I State I Zio
95 Pinewood Mill Spring NC 28756 95 Pinewood Mill Spring NC 28756
Trail Trail
Additional Financially Responsible Parties
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:
Registered Agent Information
AI Y...n I Cm-ll I Datln-s— DI.c..n I Mcb!!n Phcn.
Frank W Reed I [e-mail] I 1-(704)-816-9712 1-(704)-816-9712
Physical Address Mailing Address
Street 1 City I State Zip Street 1 City State Zip
1701 Park Rd Charlotte NC 28203 1701 Park Rd Charlotte NC 28203 -
(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:
North Carolina Agent Information
Name i Email Business Phone Mobile Phone
Frank W Reed I [e-mail] 1-(704)-816-9712 1-(704)-816-9712
Physical Address E Mailina Address
Street 1 City State . Zip Street 1 City State Zip
1701 Park Rd Charlotte NC 28203 1701 Park Rd Charlotte NC 28203
Engineering/Consulting Firm Information
Name I Email Business Phone Mobile Phone
Physical Address I Mailina Address
Street 1 City State Zip Street 1 City State Zip

Additional Details
1. Stream Classification: C:Aquatic Life,Secondary Contact Recreation, Fresh water
2. Was Express Review Requested: No
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.
,�,n 0�J a �e,c �lrP� D� ��� LUG C'a U-�Y�`�
See a-H-kked docu ►iie n-I ) Z 105 12_023

Acknowledgment Notary Certificate (Only for use in AR, AZ, CO, CT, DC, DE, GA, ID, IA, IL, KS, KY, MA,
MD, ME, MN, MO, MT, NH, NJ, NM, NY, NV, NC, OH, OK, OR, PA, RI, SC,TX, UT, VA, WA)
Document Name:b ha tin G I respDnsi hl 1 i j 1 QL heish ip. FpY w.
STATE OF N\D 'h 0.00)10
COUNTY OF L7(tbrl
(County where notarization occurred)
This record was acknowledged before me on (11 1 1 day of D 4.Yr.ber , 2023 , by
'Tim()My Vitl-w,eA rihi✓iphL (name(s)of signer(s)), who personally appeared before me and
(is personal known to me or whose ide ty was proved on the basis of satisfactory evidence)to be the person
whose name is subscribed to in this document.` % iNtss9 �oN to`.G'
} 01 ARY`%71 (Sin re of notary public)
'U
7.
` ('U8�- 4>i = r Nota Public
5�'QusT?s='�', (Name of notary public)
TON_Co'3
My commission expires:all. 2 R, 202 3
Official Seal
Personally known OR Produced identification Type of identification produced: NO"---)L
00-74-0509NSBW 12-2020