NCC240019_FRO Submitted_20240105

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name H L-0004
2. Location of land-disturbing activity: County Catawba City or Township Hickory
17th St NW 35.7449 -81.3672
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:AS Soon As Permit is Received
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Municipal
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.6
6. Amount of fee enclosed: $ 500 . 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 Kelly Winkler, PE E-mail Address [e-mail]
Phone: Office# 828-323-7431 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Signature Holdings LLC
Name Phone: Office# Mobile#
PO Box H 1718 9th Ave NW
Current Mailing Address Current Street Address
Granite Falls NC 28630 Hickory NC 28601
City State Zip City State Zip
10. Deed Book No.2644 Page No.51 7 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.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
City of Hickory [e-mail]
Company Name E-mail Address
76 North Center St NE Same
Current Mailing Address Current Street Address
Hickory NC 28601
City State Zip City State Zip
Phone: Office# 828-323-7431 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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
City of Hickory 828-323-7431 828-578-9660
Name Phone: Office# Mobile#
PO Box 398 944 18th St PI NW
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28601
City State Zip City State Zip
Deed Book No.3771 Page No.785 Provide a copy of the most current deed.
Landowner 3 of Record:
Board of Trustees of the Endowment Fund of Appalachian State University
Name Phone: Office# Mobile#
438 Academy St 800 17th St NW
Current Mailing Address Current Street Address
Boone NC 28608 Hickory NC 28601
City State Zip City State Zip
Deed Book No.3705 Page No. 169 Provide a copy of the most current deed.
Landowner 4 of Record:
The Rosemyr Corporation
Name Phone: Office# Mobile#
PO Box 108 901 Hwy 321 NW
Current Mailing Address Current Street Address
Henderson NC 27536 Hickory NC 28601
City State Zip City State Zip
Deed Book No.2843 Page No. 1 881 Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

(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.
N/A
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.
Warren Wood City Manager
Type or print name Title Qr Authority
kfL--W5- t ‘ -' ) ' -2-"L
Signature Date
I, 06St j ZQVq ICK 1/a 7.i vZ , a Notary Public of the County of I(A,r
State of North Carolina, hereby certify that Warr on W ODd 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 3 day of Novel/ilia,/ , 20 ZL
FBurke County, North Carolina .f4� _ /at �e
r{ ` ;_ 41otary Public 0y
Deisy Zavala Vazquez My commission expires 0 - 0/ - 13