NCC220669_FRO Submitted_20220211

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Dew Sharpe Road: Off -site borrow area
2.
3.
4.
Location of land -disturbing activity: County Guilford City or Township Glbsonvllle
Highway/Street Dew Sharpe Rd. Latitude 36.092226
Longitude -79.556877
Approximate date land -disturbing activity will commence: May 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.00
$1,400 (Updated Nov. 19 2021)
6. Amount of fee enclosed: $ . The Express Permitting application fee is a dual charge.
$100 The normal fee of per acre is assessed without a ceiling amount. In addition, the Express
Permitting supple ent is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Arnold Sykes Email [e-mail]
Telephone [phone] Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Dew Sharpe, LLC
336-292-7704 ext. 2
Name
Telephone Fax Number
3705-A W. Market Street
3705-A W. Market Street
Current Mailing Address
Current Street Address
Greensboro, NC 27403
Greensboro, NC 27403
City State Zip
City State Zip
10. Deed Book No. 8359 Page No. 2125 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.
Dew Sharpe, LLC
[e-mail]
Name
E-mail Address
3705-A W. Market Street
3705-A W. Market Street
Current Mailing Address
Current Street Address
Greensboro, NC 27403
Greensboro, NC 27403
City State Zip
City State Zip
Telephone [phone] ext 2
Fax Number 336-292-4200

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
City
Telephone,
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation.
Borum, Wade and Associates, P.A. [e-mail]
Engineering Firm or other consultant E-mail Address
James McGinley 336-812-1798 336-275-3719
Individual contact person (type or print) Telephone Fax Number
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.
Cranford A. Jones
Type or print name
C
Signature
Manager
Title or Authority
I-2-Z?-Z/
Date
a Notary Public of the County
State of North Carolina, hereby certify that
before me tN§,c*vaj4,being duly sworn acknowled66c
Witnega�I nd ar�3, rind seal, this day of
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G) SealUBOG
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the abgOe form was executed by him.
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