NCC233407_FRO Submitted_20231219

Check if this project is ARPA-funded ❑
NC Department of "` Attach a copy of the Letter of Intent to Fund
Environmental Quality
ReNANCIAL RESPONSIBILITY/OWNERSHIP FORM
nr7 7 7DIMENTATION POLLUTION CONTROL ACT
No person naay,in(tia QRnjdisturbing activity on one or more acres as covered by the Act, including any
activity under a p of development of this size as covered by the NCGO1 permit, before this form
and an acceptaBbPsedimentation 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.) 1)IJL ,� / , ‘ -RT)
Part A. `�
1. Project Name Mocksville Redi-Mix Plant
*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: County Davie City or Township Mocksville
322 Bethel Church Road 35.897032 -80.536537
Highway/Street Latitude(decimal degrees) Long itude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 12/1/23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.34
6. Amount of fee enclosed: $400 . 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 El Enclosed Cl No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jason Speer E-mail Address [e-mail]
Phone: Office# 336-969-0446 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Annie Speer 336-969-0446 336-345-3202
Name Phone: Office# Mobile#
PO Box 95 100 Anderson Street
Current Mailing Address Current Street Address
Rural Hall, NC 27045 Rural Hall, NC 27045
City State Zip City State Zip
10. Deed Book No. 1245 Page No. 999 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).
Forsyth Redi-Mix, Inc [e-mail]
Company Name E-mail Address
100 Anderson Street 100 Anderson Street
Current Mailing Address Current Street Address
Rural Hall, NC 27045 Rural Hall, NC 27045
City State Zip City State Zip
Phone: Office# 336-969-0446 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 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.
Type rint e Title or AUthorit
Yp Y
a3
Signature Date
I, Ft(fletio r N J cIi,c , a Notary Public of the County of Svcr i
State of North Carolina, hereby certify that /1 n✓)fe 5 p ee c 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 In day of alebe,r , 20 a 3
0.1440tyl
\\ogR ����/, Notary
H �
• v Notary Public y2 My commission expires Oe - " a 0
Surry
County _—
My Comm. Exp.
2 02-23-2027
0/����/i,��H'C A R` \''