NCC241773_FRO Submitted_20240610

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 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 PACE of Guilford & Rockingham Counties, Inc.
2. Location of land-disturbing activity: County Forsyth City or Township Winston-Salem
Highway/Street 1741 Motor Road Latitude decimal degrees 36.15497 -80.21611
( ) Longltude(decimai degrees)
3. Approximate date land-disturbing activity will commence: Summer, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Adult Day Care
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.84 acres
6. Amount of fee enclosed: $ 500'00 . 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 II No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jerry Hayes E-mail Address [e-mail]
Phone: Office# 336-545-5391 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Winston Salem,do Travis Cackerham,Real Estate Administrator 336-734-1291
Name Phone: Office# Mobile#
PO Box 2511 100 East First Street, Suite 441
Current Mailing Address Current Street Address
Winston.-Salem, NC 27102 Winston-Salem, NC 27101
City State Zip City State Zip
10. Deed Book No. 1 1 0 r-7 Page No.5 16 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 owners)may be listed as the financially responsible party(ies).
PA eV-- Ai F
I 6uI.+)PC [e-mail]
Compan ame / E-mail Address
1471 E. Cone Boulevard 1471 E. Cone Boulevard
Current Mailing Address Current Street Address
Greensboro, NC 27405 Greensboro, NC 27405
City State Zip City State Zip
Phone: Office# 336-550-4040 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#
1
Name of Individual to Contact(if Registered Agent is a company)
(b) If the FinanciallyResponsible Party not a resident of North Carolina,
p isgive 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.
PACE of the Triad
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.
Ursula Robinson President / CEO
T pe or print name Title or Authority
"),4- d. ,/i:wey-t.___,)‘aft/urie Date ���
A,I, AM) C ' 'Th I , a Notary Public of the County ofEtALL2)_&_.C4
I � II
State of North Carolina, hereby certify that �11SLt ) cRO)O1VJ3bV 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 )2- day of AA , 20 2.3
`„pp111f,I1�lq�� 0
- i)iir,
0
�,,.���, POSE.'%., Notary
f " 2.3120
�r. ; �' �4 = My commission expires
NOTARY ; U
I. 0± PUBLIC q, ;z
Ja '
Ow;CO,

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:
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 3 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 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.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#