NCC222903_FRO Submitted_20220818

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
2
3
4
5
6
7
rIa
9
Project Name Poet's Walk - Phase 3
Location of land -disturbing activity: County Guilford City or Township Gibsonville
Highway/Street NC HWY 61 Latltude(decimal degrees) 3 � - 0 fl Longltude(decimal degrees) _79. rb
Approximate date land -disturbing activity will commence:
Purpose of development (residential, commercial, industrial, institutional, etc.). Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.63 ac
Amount of fee enclosed: $ 1500 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brad Dyer E-mail Address [e-mail]
Phone: Office # 980-721-0919 Mobile # n/a
Landowner(s) of Record (attach accompanied page to list additional owners):
MTS TRI, LLC 919-699-2191
Name Phone: Office #
2857 Westport Road 2857 Westport Road
Current Mailing Address
Charlotte NC 28208
City State
10. Deed Book No. 8599
Mobile #
Current Street Address
Charlotte NC 28208
Zip City
Page No. 184-190
State
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).
MTS TRI, LLC
Company Name
2857 Westport Road
Current Mailing Address
Charlotte NC 28208
City State Zip
Phone: Office # 704-399-4663
[e-mail]
E-mail Address
2857 Westport Road
Current Street Address
Charlotte NC 28208
City State
Mobile # [phone]
Zip
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:
MTS TRI, LLC- Clark J Stewart [e-mail]
Name of Registered Agent
2857 Westport Road
Current Mailing Address
Charlotte NC 28208
City
E-mail Address
2857 Westport Road
Current Street Address
Charlotte NC 28208
State Zip City
Phone: Office # 704-399-4663
Clark J Stewart
Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
Joe F Polite Jr.
Type or print
Title or Authority
4/12/22
ure Date
Kaitlyn Salley
, a Notary Public of the County of Mecklenburg
State of North Carolina, hereby certifythat Joe F. Polite Jr. 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 12th day of April
Kaitlyn Salley
NOTARY PUBLIC
Mecklenburg County
SEWrth Carolina
My Commission Expires April, 27, 2025
2022
AVy— .
otary
My commission expires 4/27/25

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.
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 8 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 #