NCC233063_FRO Submitted_20231012

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT(APRIL 2023)
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 200 Lantana Drive-Providence Pointe
2. Location of land-disturbing activity: County Randolph City or Township Archdale
Highway/Street Suits Road Latitude(decimai degree 5-893506 Longitude(decimal degrees) 79.917996
3. Approximate date land-disturbing activity will commence: Fall 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 117 AC
6. Amount of fee enclosed: $ . 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 ❑ Enclosed © No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
James Floyd E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Kepley Frank Hardwood Co. Inc. 336.746.5419
Name Phone: Office# Mobile#
975 Conrad Hill Mine Rd 975 Conrad Hill Mine Rd
Current Mailing Address Current Street Address
Lexington NC 27292 Lexington NC 27292
City State Zip City State Zip
10. Deed Book No. 002001 Page No. 00362 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 names)of the owner(s)may be listed as the financially responsible party(ies).
MG Suits, LLC [e-mail]
Company Name E-mail Address
4030 Wake Forest Road 4030 Wake Forest Road
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
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:
James Floyd [e-mail]
Name of Registered Agent E-mail Address
PO Box 10784 PO Box 10784
Current Mailing Address Current Street Address
Greensboro NC 27408 Greensboro NC 27408
City State Zip City State Zip
Phone: Office# Mobile# [phone]
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.
JA-4tPS ``4 v l/' 4 Lf er a.Type or print name Title or Authority'
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Sign ure Date
Ir1�` L '` c\y\`YVY' S , a Notary Public of the County of (7 \ l y ol
State of North Carolina, hereby certify that \J 'I J 0\ appeared personally
before me this day and being duly sworn acknowledged that the ove form was executed by him/her.
Witness my hand and notarial seal, this 21 day ofce0C 20
ZC'UUAg)\\n\(VVV\j
Notary BAILEY SIMMONS I My commission expires \AQ 12 l l
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Notary Public
Guilford Co.,North Carolina
My Commission Expires June 27,2026