NCC210986_ESC Approval Submitted_20210225

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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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
Project Name Royal Pines Subdivision Phase 5
2. Location of land -disturbing activity: County Randolph City or Township Archdale
Highway/Street Archdale Road Latitude 35.863 Longitude-79.932
3. Approximate date land -disturbing activity will commence: January, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
25.2 AC/252 AC Basin
6_ Amount of fee enclosed: Included in TRC fees .
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott Wallace E-mail Address swallaceCa_aokeystone.com
Telephone [phone] Cell #
Fax #
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
W. Scott Wallace President
Type or print name
Signature
i, illa11ee
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him.
Witness my hand and notarial seal, this
L TEikliPLE VfALLACE
V40TARY PUBLIC
GUILFORD COUNW, NC
COmmIe01on lixplr®a _t 2--2-- 7-2
Seal
Title or Authority
1/1312,o-, i(
Date
a Notary Public of the County of
(!; V t L_F-.pJz'0
- S �T__' Wa i I a ` " appeared
duly sworn acknowledged that the above form was
3 day of a��a, -y 20 Z I
Notary
My commission expires t 2- I - ��