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HomeMy WebLinkAboutNCC222845_FRO Submitted_20220812FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.) Part A. I. Project Name Reedy Fork Ranch Tract 21 2. Location of land -disturbing activity: CountyGuilford City or Township Greensboro Hi hwa /Street5770 Eckerson Rd. 36-171030-79.709594 g y LatltUde[decimal degrees) LDngit4.ldE�degmai degrees] I Approximate date land -disturbing activity will commence: 7-27-22 4. Purpose of development {residential, commercial. industrial, institutional, etc.}: Commercial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 1 .5 6. Amount of fee enclosed: $ N/A . 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. 10 Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Kevin Pegram E-mail Addresskevin@kyIindservices.com Phone: Office # 336-669-3209 Mobile # 336-669-3209 Landowner(s) of Record (attach accompanied page to list additional owners): AF-Reedy Fork LLC 919-861-2929 Name Phone: Office # 919 Mobile # 1330 Sunday Drive Suite 105 1330 Sunday Drive Suite 105 Current Mailing Address Current Street Address Raleigh NC 27607 Raleigh NC 27607 City State Zip City State Zip Deed Book No. 007425 Page No. 00292 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). AF-Reedy Fork LLC Company Name 1330 Sunday Drive Suite 105 Current Mailing Address Raleigh NC 27607 City State Zip Phone: Office # 91 9-861-2929 WJackson@greenhawkcorp.com E-mail Address 1 330 Sunday Drive Suite 105 Current Street Address Raleigh NC 27607 City State Zip Mobile # 919 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: Name of Registered Agent Current Mailing Address City State Zip Phone: Office # E-mail Address Current Street Address C ity Mobile # Name of Individual to Contact (if Registered Agent is a company) State Zip (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: Name of Registered Agent Current Mailing Address City State Phone: Office # E-mail Address Current Street Address Zip City Mobile # Name of Individual to Contact (if Registered Agent is a company) State Zip (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. 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, Linwood A. Jackson Type a tint narrip A0v,� Si4datlire Manager Title or Authority - 2-7-2Z_ Date M9?AOrA1& a Notary Public of the County of State of North Carolina, hereby certify that appeared personally before me this day and being duly sworn acknowledged that the above form was executed by himlher. Witness my hand and notarial seal, this day of 20-- �,?— act-- Notary My commission expires r'i '2LO;-6 .%# MCR �s`� pTAR Wiry Comm. Exp. 02-19.2025 00 UB30 . co untl