NCC231535_FRO Submitted_20230526

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 N/A in the blank.)
Part A.
1. Project Name Edinborough Phase 6
`If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: CountyGuilford City or Township Rock Creek
0
Highway/Street 5613 NC Highway 61LNatitude(decimal degrees) 36.119Longitude(decimal degrees) -79.5510
3. Approximate date land-disturbing activity will commence:5/29/20
4. Purpose of development(residential, commercial, industrial, institutional, etc.):43 RES. LOTS
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 15.67
6. Amount of fee enclosed: $ 1 ,600.00 . 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 ✓❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameChad Hill E-mail [e-mail]
Phone: Office# 336-369-2188 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Edinborough 7 LLC 336-369-2188
Name Phone: Office# Mobile#
7B Corporate Center Court 7B Corporate Center Court
Current Mailing Address Current Street Address
Greensboro NC 27408 Greensboro NC 27408
City State Zip City State Zip
10. Deed Book No.8381 Page No.2712 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).
Edinborough 7 LLC [e-mail]
Company Name E-mail Address
7B Corporate Center Ct 7B Corporate Center Ct
Current Mailing Address Current Street Address
Greensboro NC 27408 Greensboro NC 27408
City State Zip City State Zip
Phone: Office# 336-369-2188 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:
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 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)

(o) 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 on individual, General
Partnanship, or other company not registered and doing business under an assumed nome, attach o copy
of the Certificate of Assumed Name.
Company O8AName
The above information is true and correct to the best nfnny 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 ind|v|duo|, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected information should there be any change in the information provided herein.
Herbert Parks
Owner
Title or Authority
8igndture ~ Date
|. / ~��^o-,«�"�` e ��~- *� . a Notary Public ofthe County of t-v���u~\
uo
State of North Carolina, hereby certify that �����=�l� S. -s�x" appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
-T'�
Witness my hand and notarial seal, this / � day of 20
Maggie Pegg Notary " ~
NOTARY PUBLIC
Forsyth County,NG W1y commission expires
\MyCommbmiooEu�mo October 04.2025|

Continued from 8en7a S & 10 /n Part of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page 88 needed tn list all landowners.
Landowner 2ofRecord:
Name Phone: Offico# 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 3ofRecord:
Name Phone Office# Niobi|e#
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 4ofRecord:
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 5ufRecord:
Name Phone: Offico# 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 I /n Part Buf the Financial Form for multiple parties.
Attach copies of this page oa needed hr list all financially responsible parties.
Company 2Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office Mobile#
Company Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone Offioa# Mobile#
Company Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# K4nbi|o#
Company Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Officm# Mobile#