NCC216134_FRO Submitted_20211104

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate a 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, Health
and Natural Resources. (Please type or print and, if question is not applicable, place N/A in the
blank).
Part A.
1. Project Name Ambergate -Phase Two
F1
3.
4,
5.
6.
Location of land -disturbing activity: County Nash
City or Township Rocky Mount and Highway/Street Freer Drive
Approximate date that land -disturbing activity will be commenced: Fail 2021
Purpose of development (residential, commercial, industrial, etc.) Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.1 AC
Amount of fee enclosed $ M.00 (Previously Paid)
7. Has an erosion and sedimentation plan been filed? Yes No
Enclosed
8. Person to contact should sediment control issues arise during land -disturbing activity.
Name Roy F. Alley III Telephone [phone]
9
Landowner(s) of Record (Use blank page to list additional owners):
James D. Chapman SAME
Names)
9751 Broockchase Drive
Current Mailing Address Current Street Address
RaleighNG 27617
City State Zip City State Zip
10. Recorded in Deed Book No. 3097 Page No. 910
Part B.
1. Person(s) or firm(s) who are financially responsible for this land -disturbing
activity (Use a blank sheet to list additional persons or firms):
Ambergate Phase II Dev LLC SAME
Name(s)
415 Pisgah Church Road f'r 33 5'
Current Mailing Address
Greensboro NC 27455
Current Street Address
City State Zip City State Zip
336-303-8558
Telephone
Telephone

2. (a) If the Financially Responsible Party is not a resident of North Carolina give name and
street address of a North Carolina Agent,
NIA
Name
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership or other person engaging
business under and 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
Registered Agent.
NIA
Name of Registered Agent
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Telephone
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 b y the financially responsible
person if an individual or his attomey-in-fact or if not an individual, an officer, director,
partner or registered agent with 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.
Roy F. Alley III Manager
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Title or Authority
Date
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I, l� u f���, A No ublic of the County of C.{
5ta a of North Carolina, hereby certify that A � ( �, t i 1
appeared personally before me this day and being duly sworn acknowle ged that the
above form was executed by him,
Witness my hand and notarial seal, this day of
". Seal r
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