NCC221280_FRO Submitted_20220405

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 NIA in the blank.)
Part A. Carolina Pines Retirement Community
1. Project Name
2. Location of land -disturbing activity: County Guilford City or Township Greensboro
Highway/Street High Point Rd Latitude 36.0203 Longitude-79.8814
3. Approximate date land -disturbing activity will commence: 4/12/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Multi -Family
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.2
8. Amount of tee enclosed: $ . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chuck Leininger E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Carolina Pines Retirement Community LLC [phone]
Name Telephone Fax Number
7101 S 82nd St 7101 S 82nd St
10,
Current Mailing Address
Lincoln, NE 68516
Current Street Address
Lincoln, NE 68516
City State Zip City
Deed Book No. 008296 Page No. 00937
State
Zip
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.
Cameron General Contractors [e-mail]
Name
7101 S 82nd St
Current Mailing Address
Lincoln, NE 68516
City State Zip
Telephone [phone]
E-mail Address
7101 S 82nd St
Current Street Address
Lincoln, NE 68516
City State Zip
Fax Number [phone]

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:
Old Republic National Title Insurance Co. [e-mail]
Name E-mail Address
223 S. West Street, Suite 900 223 S. West Street, Suite 900
Current Mailing Address Current Street Address
Raleigh NC 27603
Raleigh NC 27603
City State Zip
City State Zip
Telephone [phone]
Fax Number 913-489-5231
(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:
Old Republic National Title Insurance Co.
[e-mail]
Name of Registered Agent
E-mail Address
223 S. West Street, Suite 900
223 S. West Street, Suite 900
Current Mailing Address
Current Street Address
Raleigh NC 27603
Raleigh NC 27603
City State Zip
City State Zip
Telephone [phone]
Fax Number 913-489-5231
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
corrected information should there be any change in the information provided herein.
Breck C. Collingsworth CEO - Manager
or print name
Title or Authority
3/29/2022
signature
--------------------------------- Q ---------------------------------------
I. L=01- I. E. ea- !U W4-tn a Notary Public of the County of LaYi LPL s4y
Ntbvasto-'
State of- Tea, hereby certify that _ �' C • eO f CIhgS L v t-- appeared
personally before me this day and being duly sworn acknowledgd that the above form was
executed by him.
Witness my hand and notarial seal, this �q d y of ��LL , 20-4
General Notary - state of Nebraska
LORI E. ODEN-MUTH Nota
My Comm. Ex . Jan. 5 2024.
My commission expires (' �J'�y� L]