NCC215754_FRO Submitted_20211015

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Covington Ridge
1. Project Name
2. Location of land -disturbing activity: County Randolph City or Township Trinity
Highway/Street Unity Street Latitude 35.872698 Longitude-80.039533
3. Approximate date land -disturbing activity will commence: Fall 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 36.61
6. Amount of fee enclosed: $ 2405 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 James Floyd E-mail [e-mail]
Telephone [phone] cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Robert Helper
N/A N/A
Name
Telephone Fax Number
5491 Jennifer Ct
5491 Jennifer Ct
Current Mailing Address
Current Street Address
Archdale NC
27263 Archdale NC 27263
City State
Zip City State Zip
10. Deed Book No. 001365
Page No. 01472 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who
are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
MG Unity, LLC
[e-mail]
Name
E-mail Address
PO Box 10784
7B Corporate Center Court
Current Mailing Address
Current Street Address
Greensboro NC
27404 Greensboro NC 27408
City State
Zip City State Zip
336-451-6479
N/A
Telephone
Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number_
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Northwest Registered Agent Services, Inc [e-mail]
Name of Registered Agent E-mail Address
4030 Wake Forest Rd. Ste 349 4030 Wake Forest Rd. Ste 349
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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.
James Floyd Manager
Type or print name Title or Authority
- a, A V Y-,2 -.'-/
Si ature Date
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WiU64�2174_ _,a Notary Public of the County of "21-wz` ,
State of North Carolina, hereby certify that tJl. m49- j �ID�GY appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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Witness my had ig l seal, this G' day of 20 07/
F NOTARY aa lo�
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