NCC223237_FRO Submitted_20220923

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any andft-disturbing activity on one or more acres as covered b the Act before
and an acceptable erosion and sedimentation control
Quality Section, N.C. Department of Environmental
Regional Office. (Please type or print and, if t
number is unavailable, place N/A in the blank.)
Part A.
plan have been completed and approved by
this form
the Land
Quality,, Submit the completed form to the appropriate
ne question is not applicable or the e-mail address or phone
9. Project NamemcDeeds Creek Bank Stabili2 zation
2. Location of land -disturbing activity: County 'Moore City or Township South, ern Pines
W. Pennsylvania Avenue 35.1763 Long itu de(ded mat degrees), w79ff3969
Highway/Street LBtItUd@decimal degrees)
3. Approximate date land -disturbing activity W ill commence: Se ptember 21 , 2022
4. Purpose of development (residential, commercIt ial, industrial, institutional, etc.l*Sp
Environmental
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas}: 153 AC
6. Amount of fee enclosed: $200.0 0 .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 ❑ N o [:]
8. Person to contact should erosion and sediment
NameKory Strader
Phone: Office#
control issues arise duror 0 ing land -disturbing activity:
E-mail Address [e-mail]
Mobile # 3364"362V=0289
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town nf Southern Pines Q I I I-Aqt?m I Q83
Name Phone: Office# Mobile #
140 Memorial Park Court
Current Mailing Address Current Street Address
Southern Pines NC 28387
City State Zip City State Zip
10w Deed Book No. Page No. 793 Provide a copy o the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Res ponsibility/Ownership Form for multiple
owners. Attach Copies of this page as needed fo list al! landowners.
Landowner 2 of Record:
CDA Golf Properties, Inc.
Name
275 S. Bennett Street
Current Mailing Address
Southern Pines
NC 28387
City State Zip
Deed Book No. 52 49
Landowner 3 of Record:
Phone: Office #
Current Street Address
Mobile #
City State Zip
pa ge No. 37 � Provide a copy of the most current deed.
Calvary Memorial Church, Inc. Trustees
Name
400 S Bennett Street
Current Mailing Address
Southern Pines
NC 28387
City State Zip
Deed Book No. 41 1
Landowner 4 of Record:
Name
Current Mailing Address
Phone: Office#
Current Street Address
Mobile #
City State Zip
Page No.650 provide a copy of the most current deed.
City State ZIL
ip
Phone: Office#
Current Street Address
Mobile #
City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record-.
Name
Current Mailing Address
City State Zip
Phone: Office #
Current Street Address
Mobile #
City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible far the land-disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page..) ff the company is a sole proprietorship or if the landowne) is
an individua(s), the names) pf the owners) maybe listed as the financially responsible party{ies)
KBS Earthworks, Inc,
Company Name
5616 Coble Church Road
Current Mailing Address
Julian NC 27283
City State Zip
Phone: Office#���-382-4866
office a khsea rthwnrkq.rnm
E-mail Address
Current Street Address
sr(
City State Z31
ip
Mobile #
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 applican# to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party IL
is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Koirw Str der
Name of Registered Agent
5616 Coble Church Road
Current Mailing Address
Julian NC 27283
City State Zip
Phone: Office# 336-362 0289
[e-mail]
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered 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
Current Mailing Address
City State Zip
Phone: Office#
E-mail Address
Current Street Address
City State Zip
Name of Individual to Contact (if Registered Agent its a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, g31.
ive 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 Icnowledge and belief and was jarovided
Oy me under oath. (This form must be signed by the Financially Responsible Person if an individuals}
or his attorney -in -fact, or if not an individual., bN an officer. director. partner_ nr r
the
Corr
autho
rity to execute instruments for the Financially Responsible Party).
ected information should there be;e nv chance
Kory Strader
ype or print na
egistered agent with
agree to provide
in the information provided herein.
President
Title or Authority
9/13/22
g Iftn u re Date
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a Notary Public v,
State of North Carolina, hereby certify that
before me this day and being duly sworn ackno
Witness my hand and notarial seal, this
f the County of
mar dgthat the above for
_appeared personally
as executed by him/her.