NCC223336_FRO Submitted_20220923

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM (REV 21 April 2022)
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 City of
Archdale ACE Integrated Stormwater Management Program. Submit the completed form and current deed to
the appropriate personnel. (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 4617 Archdale Road (Lancaster Customworks)
2. Location of land -disturbing activity: County_Randolph City or Township_ Archdale
Highway/Street 4617 Archdale Rd_ Latltude(decimal degrees)_35.895480 Longltude(decimal degrees)-79.962783
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.2
6. Amount of fee enclosed: $ $0 . The application fee is defined in the published
City of Archdale fee structure which is typically $0 when a Technical Review Committee (TRC) evaluation
is required. Checks should be addressed to City of Archdale.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Danny Burton
Phone: Office # 336-362-5671
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Grace Bay Properties LLC _336-431-6655
Name Phone: Office #
402 Interstate Drive_ 402 Interstate Drive
Current Mailing Address Current Street Address
_Archdale NC 27263
City State
Zip City
Archdale NC 27263_
State
_n/a_
Mobile #
Zip
10. Deed Book No. 2787 Page No._1395_ 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
_Lancaster Customworks Inc
Company Name
402 Interstate Dr_
Current Mailing Address
Archdale NC 27263
City State
[e-mail]
E-mail Address
402 Interstate Dr
Current Street Address
Archdale NC 27263
Zip City State Zip
Phone: Office* 336-431-6655 Mobile #
nra
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:
nla
Name of Registered Agent
n/a
Current Mailing Address
n/a
City State Zip
n/a
E-mail Address
nla
Current Street Address
n/a
City State Zip
Phone: Office # n/a Mobile # n/a
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:
George Lancaster
Name of Registered Agent
402 Interstate Dr
Current Mailing Address
—Archdale NC 27263
City State
Phone: Office # 336-431-6655
[e-mail]
E-mail Address
402 Interstate Dr
Current Street Address
Archdale NC 27263
Zip City
Mobile # nla
State Zip
Name of Individual to Contact (if Registered Agent is a company)

(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.
George Lancaster Registered Agent
Type or print name Title or Authority
Signature Date
I. �k_Gt%1y-a h P, ,, v)a-n, a Notary Public of the County of
State of North Carolina, hereby certify that L- eorc�_' appeared personally
before me this day and being duly sworn ackgpwle - ged that the above form was executed by him/her-
Witness my hand and notarial seal, this day of 1' , 20
Z
BUNTONPUBLIC Notary
OUNrr, NCpo ee 11.19-2024 My commission expires_ <<

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 fist all landowners.
Landowner 2 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 3 of Record:
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 4 of Record:
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book No.`
Landowner 5 of Record:
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
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.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address
City
Phone: Office #
Current Street Address
State Zip City
Mobile #
State Zip
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Phone: Office #
Zip City State
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Phone: Office #
Zip City State
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Phone: Office #
Zip City State
Mobile #
Zip
Zip