NCC220972_FRO Submitted_20220308

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 Wexford — Phases 1-2
2. Location of land -disturbing activity: County Alamance City or Township Elon
Highway/Street Gibsonville Ossipee Rd Latitude 36.122 Longitude-79.526
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_37.00 acres
6. Amount of fee enclosed: $_2,405.00 . 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 —Brad Dyer E-mail Address—[e-mail]
Telephone_980-721-0919 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Joe Polite — MTS TRI. LLC 704-574-7877
Name Telephone Fax Number
2857 Westport Road Same
Current Mailing Address Current Street Address
Charlotte NC 28208 S
City State Zip City
State
Zip
10. Deed Book No. 2954 Page No. 0073 Provide a copy of the most current deed.
Part B.
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.
MTS TRI, LLC
Name
2857 Westport Road
Current Mailing Address
Charlotte NC 28208
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
Same
Current Street Address
Same
City
Fax Number
State Zip

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:
MTS TRI, LLC [e-mail]
Name E-mail Address
2857 Westport Road Same
Current Mailing Address Current Street Address
Charlotte NC 28208 Same
City State Zip City State Zip
Telephone [phone] Fax NUmher
(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 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
corrected information should there be any change in the information provided herein.
Joe Polite Vice President
Type or print name Title or Authority
L. .
Si ture V Dat
t, CA 'r a Notary Public of the County of
State of North Carolina, hereby certify that 1 �e ���_� I 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 ��Wi day of U , 20��
Kaitlyn Salley
NOTARY PUBLIC
Mecklenburg County N tary
Seal North Carolina
My Commission Expires April, 27, 2025 My commission expiresV I �J