NCC221498_FRO Submitted_20220418

environmental Quality
Received
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM MAR 0 4 2022
SEDIMENTATION POLLUTION CONTROL ACT
Winston-Salem
No person may initiate any land -disturbing activity on one or more acres as covered by the Act R%9iiE)
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Rivers Edge Farms
2. Location of land -disturbing activity: County Rockingham City or Township Mayo
Highway/Street River Road SR 2150 Latitude(decimal degrees) 36.4066 LongitUde(decimai degrees) = 79.9332
3. Approximate date land -disturbing activity will commence. March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 18.1
6. Amount of fee enclosed: $1.900.00. The application fee of $100.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: 8.10-acre application fee is $900). Checks should be
addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed X No 0
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Charles Rakestraw E-mail Address [e-mail]
Phone: Office # 336 552 6402 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rakestraw Investment Company, Inc.
Name
205 Hampton Street
Current Mailing Address
Stoneville NC 27048
336 552 6402 336 552 6402
Phone: Office # Mobile #
205 Hampton Street
Current Street Address
Stoneville NC 27048
City State Zip City State Zip
10. Deed Book No. 990 Page No.687 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of
all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) maybe listed as the financially responsible party(ies).
Rakestraw Investment Company, Inc
Company Name
205 Hampton Street
Current Mailing Address
Stoneville NC 27048
City State Zip
Phone: Office # 336 552 6402
crakestraw123(a_)amail. corn
Email Address
205 Hampton Street
Current Street Address
Stoneville NC 27048
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Charles Rakestraw crakestraw123(a-bgmail.com
Name of Registered Agent Email Address
205 Hampton Street
Current Mailing Address
Stoneville NC 27048
City State Zip
Phone: Office: 336 552 6402
Hampton Street
Current Street Address
Stoneville NC 27048
City Stae Zip
Mobile: [phone]
name or inaiviauai to contact fir rcegisterea Agent is a company)

(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of
Registered Agent ail Address
Current
Mailing Address Current Street]Address
State Zip City State Zip
Phone: Office #
Name of Individual to Contact (if Registered P

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s) 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 Party). I agree to
provide corrected information should there be any change in the information provided herein.
C_h c:-,�e_s Bctiic-ej i-r'mernbec
Type or print name Title or Authority
C +_� U a - a-3
Signature Date
I, lLqA�uu'l hug , a Notary Public of the County of 44 �T-IJ
State of North Carolina, hereby certify that 1 .�nn,d�C'S �l�Tr� appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by
him/her.
Witness m :hii vtarial seal, this day of w 20 _
0 TA •�
Notary
�_6Ao �LIC
f��,,,�°�.� ��� My commission expires
ContinuT z 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Atfddh,6;W�of this page as needed to list all landowners.
Landowner 2 of Record:
Phone: Office # Mobile #
Mailing Address Current Street
State Zip City State Zip
Deed Book No. Pkge I\
lame
Current
City
!nt deed.