NCC230750_FRO Submitted_20230320

NC Departmesit ,.,I"
Environrnental Quail",/
Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JAPE 12 2023
SEDIMENTATION POLLUTION CONTROL ACT
Winston-S-Tenn
No person may initiate any land -disturbing activity on one or more acres as covered by the Phi � ��gl t I -form
and an acceptable erosion and sedimentation control plan have been completed and approVd 'by t Sd
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 N/A in the blank.)
Part A.
1
2.
3.
4.
4jM/L� f �� -0zU
Project Name Hillsdale Ridge Townhomes
Location of land -disturbing activity: County Davie City or Township Bermuda Run
Hillsdale West Drive 35.9962-80.4509
Highway/Street LatltUde(decimalaegrees) LOngltUde(decimal degrees)
Approximate date land -disturbing activity will commence: Upon Permitting
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
12.52
6. Amount of fee enclosed: $ 1300 . 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
9
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad Fuller E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Fuller Land Company LLC
Name
1508 County Home Road
Current Mailing Address
Mocksville, NC 27028-8139
City
10. Deed Book No. 972
State Zip
[phone]
Phone: Office # Mobile #
Current Street Address
City State Zip
Page No. 765 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).
Fuller Land Company LLC
Company Name
1508 County Home Road
Current Mailing Address
Mocksville, NC 27028-8139
[e-mail]
E-mail Address
Same
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile # [phone]
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # 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.
Chad Fuller Member -Manager
Type nrl#� me Title or Authority
/
Signature Date
a Notary Public of the County of \
State of North Carolina, hereby certify thatLad FwVECappeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and ni��rial seal, this �� day of OV , 2 2�
Q.• �fill
-�p
VM= ry
p PUBLIC V My commission expires
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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 list all landowners.
Landowner 2 of Record:
Phillip E. & Darlene S. Fuller
Name
980 Salisbury Road
Current Mailing Address
Mocksville, NC 27028
City State
Deed Book No. 839
Landowner 3 of Record:
Phone: Office # Mobile #
Same
Current Street Address
Zip City
Page No. 820
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
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.
Landowner 4 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
Mobile #
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.