NCC223998_FRO Submitted_20221202

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name The Lofts at Elmsley Crossing
2. Location of land -disturbing activity: County Guilford _ City or Township Greensboro
Kallamdale Road N36.002329 W-79.901655
Highway/Street Latitude(eaamei degrees) Longitude(aeGmel degrees)
3. Approximate date land -disturbing activity will commence: June 20 `[2
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Multi -Family Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.5
6. Amount of fee enclosed: $ 700 _. 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 © No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJos h Ryan Hamilton E-mail AddressryanhamiltonCahamiltoncorporation.com
Phone: Office # 417-882-1701 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Robert M Layton
Name
7258 Strawberry Road
Phone: Office #
Current Mailing Address Current Street Address
Summerfield NC 27358
City State
10. Deed Book No. 35 33
Zip City
Mobile #
State Zip
Page No. 8 9 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) may be listed as the financially responsible party(ies).
The Lofts at Elmsley Crossing, LLC [e-mail]
Company Name E-mail Address
3556 S. Culpepper, Ste 4
Current Mailing Address Current Street Address
Springfield MO 65804
City State Zip City State Zip
Phone: Office # 417-882-1701 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 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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip 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.
Registered Agent Solutions, Inc.
Name of Registered Agent
176 Mine Lake Court, Ste 100
Current Mailing Address
Raleigh NC 27615
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(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.
Joseph Ryan Hamilton
Type or
Member
Title or Authority
3-al-aa
Date
I, a Notary Public of the County of
�SSOU c' �.
State of f, hereby certify that moo; \-) E,ao,n VkakL �-�e appeared personally
before me this day and being duly sworn acknowlddged thdt the above form was executed by him/her.
Witness my hand and notarial seal, this
ELIZAKTH R. SCHULTE
Not&ry Public - Notary Seal
Stateiu�fiber:
Missouri
Commissioned Christian County
+� CgMmissionMs: May 11, 2022
Commission 14883619
day of m"�h , 20 ate_
a
My commission expires Clan I, c�

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
David P Layton, Charlotte M Layton
Name Phone: Office # Mobile #
6412 Lake Brandt Road
Current Mailing Address Current Street Address
Summerfield NC 27358
City State Zip City State Zip
Deed Book No. 54 Page No. 92 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record:
Name
State
Current Mailing Address
City State
Deed Book No._
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No.
Phone: Office # Mobile #
Current Street Address
Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Zip City
Page No.
Mobile #
State ZiD
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.