NCC221641_FRO Submitted_20220506

�4C Dept of Environmental Qual
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
SFP 15 2021
Raleigh R Tonal Office
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before I is
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. Maple Ridge
1. Project Name
Maple
Location of land -disturbing activity. County Franklin City or Township Frankllnton
Highway/Street Cedar Creek Rd Latitude 36.075140 Longitude -78.433450
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas �• $3� .
6. Amount of fee enclosed: $2,405 . 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
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeff White E-mail Address [e-mail]
Telephone cell # (919)-422-5741 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AF Forest City LLC (919)-422-5741
Name Telephone Fax Number
1330 Sunday Dr 1330 Sunday Dr
Current Mailing Address Current Street Address
Raleigh, NC, 27606 Raleigh, NC, 27606
City State Zip City State Zip
10. Deed Book No, 1970 Page No. 133 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.
Name GHO-MVIG 9;41
1330 Sunday Dr
Current Mailing Address
Raleigh, NC, 27606
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
1330 Sunday Dr
Current Street Address
Raleigh, NC, 27606
City State Zip
Fax Number

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
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 of Registered Agent 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.
Jeff White
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Date
I. a Notary Public of the County of
State of North Carolina, hereby certify that 7 Nh, le- 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 f day of Aw U4 20
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