NCC220478_FRO Submitted_20220125

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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name: Levington Subdivision Phase 1
2. Location of land -disturbing activity: County: Rockingham City or Township: Stokesdale
Highway/Street: Carlton Road Latitude: 36.3083° Longitude: 79.9383'
3. Approximate date land -disturbing activity will commence November 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.03 acres
6. Amount of fee enclosed: $ 585.00 . 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: XX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Ken Chavis
Telephone: [phone]
E-mail Address: kchavis(aD.cipconst.com
Cell # [phone] Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Esther B Tuttle N/A
Name Telephone Fax Number
494 Tate Road
Current Mailing Address
Reidsville NC
City State Zip
494 Tate Road
Current Street Address
Reidsville NC
City State Zip
10. Deed Book No 03 Page No. 788 Provide a copy of the most current deed.
Part B.
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.
Carrolland Corporation
Name
PO Box 9846
Current Mailing Address
Greensboro NC 27429
City State Zip
aleonard(a)-thecarrollcom pan ies. com
E-mail Address
201 North Elm St, Suite 201
Current Street Address
Greensboro NC 27401
City State Zip
Telephone: [phone] Fax Number: N/A

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
Current Mailing Address
E-mail 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:
John Lasala, CFO jlasalaCa�thecarrollcompanies.com
Name of Registered Agent E-mail Address
PO Box 9846 201 North Elm St, Suite 201
Current Mailing Address Current Street Address
Greensboro NC 27401 NC NC 27401
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.
John Lasala Chief Financial Officer
Type or print name Title or Authority
k 9 h?,,
Sign a e Date
I,
'4h
a Notary Public of the County of fo
Ir "(I
State of North Carolina, hereby certify that-���r��w ��i appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this
STUA9'L�AUFMA_N
Notary Pu i , North Carolina
Guilford County
My Commi sion xpires
t � �
day of 2021
Notary
My commission expires

Landowner(s) of Record (attach accompanied page to list additional owners):
Moore Real Estate Investments LLC N/A
Name Telephone Fax Number
P. O. 37
Current Mailing Address
Summerfield NC 27358
City State Zip
Current Street Address
NC _
City State Zip
10. Deed Book No 1557 Page No. 1316 Provide a copy of the most current deed.