NCC230746_FRO Submitted_20230321

FINANCIAL 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.
1. Project Name PARK RIDGE
2. Location of land -disturbing activity: County Surry City or Township Elkin
Highway/Street NC HVVY 268 W Latitude(decimal degrees) 36,2525 Longitude(decimai degrees)-80.8646
3. Approximate date land -disturbing activity will commence: January 2023
Residential, Single-family and
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Multi -Family
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.80
6. Amount of fee enclosed: $ 800.00 . 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 2 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Michaels, Company Agent E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Park Ridge Partners, LLC (Tract 1) [phone]
Name
P.O. Box 9147
Current Mailing Address
Greensboro, NC 27429
City State
10. Deed Book No. 1831
91
Phone: Office #
Mobile #
1007 Battleground Avenue, Ste 301
Current Street Address
Greensboro, NC 27408-8313
City State
Page No. 527
Zip
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).
Park Ridge Partners, LLC
Company Name
P.O. Box 9147
Current Mailing Address
Greensboro, NC 27429
City State
Phone: Office # [phone]
E-mail Address
1007 Battleground Avenue, Ste 301
Current Street Address
Greensboro, NC 27408-8313
Zip City State Zip
Mobile #
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:
Thomas C. Hall
[e-mail]
Name of Registered Agent
E-mail Address
P. O. Box 9147
1007 Battleground Avenue, Ste 301
Current Mailing Address
Current Street Address
Greensboro, NC 27429
Greensboro, NC 27408-8313
City State
Zip City State Zip
Phone: Office # [phone]
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
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)

(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.
Park Ridge Partners, LLC
Thomas C. Hall Manager
TypZ
print name Title or Authority
4
Signature Date
6 o [f e_1 �-�-, 1 +-0 V1 a Notary Public of the County of Gat �
State of North Carolina, hereby certify that �r✓o i YtA- (-' LLiLz appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this
Seal
'� d yof eU L'J.r ,„ 20
Notary
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 list all landowners.
Landowner 2 of Record:
Worth Winebarger Properties, LLC ET AL. (Tract 2) [phone]
Name Phone: Office # Mobile #
790 Macedonia Church Road
Current Mailing Address
Rhonda, NC 28670-9145
City State
Deed Book No. 1484
Landowner 3 of Record:
Name
Current Street Address
Zip City
Page No. 971
State Zip
Provide a copy of the most current deed.
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.
Landowner 4 of Record:
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.
Landowner 5 of Record:
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.