NCC224076_FRO Submitted_20221212

N �� vepai tment of
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Environmental quality
SEDIMENTATION POLLUTION CONTROL ACT (Receigved
gm
No person may initiate any land -disturbing activity on one or more acres as covered by the Act 6efohP
and an acceptable erosion and sedimentation control plan have been completed and appC9YROt8� the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form Ito,the a� ro ®ne
Regional Office. (Please type or print and, if the question is not applicable or the a-malAte
il adc�
number is unavailable, place N/A in the blank.) OACK) Z023 N
Part A. /�
1. Project Name Rivers Edge Farms, Phase 2 Lots 32-55
2. Location of land -disturbing activity: County Rockingham City or Township Mayo
River Road SR 2150 36.4066-79.9332
Highway/Street Latitude(decimai degrees) Long itude(decimai degrees)
3. Approximate date land -disturbing activity will commence:
November 29, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5'8
6. Amount of fee enclosed: $ 600.00 . 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 ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Charles Rakestraw E-mail [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. 336 552 6402
10
Name
205 Hampton Street
Current Mailing Address
Stoneville NC
City State
Deed Book No. 990
Phone: Office #
205 Hampton Street
Current Street Address
27048 Stoneville NC
336-552-6402
Mobile #
27048
Zip City State Zip
Page No. 687 Provide a copy of the most current deed.

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).
Rakestraw Investment Company, Inc.
Company Name
205 Hampton Street
Current Mailing Address
Stoneville NC 27048
City State Zip
Phone: office # 336-552-6402
crakestrawl [e-mail]
E-mail Address
205 Hampton Street
Current Street Address
Stoneville NC 27048
City State
Mobile # [phone]
M
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
Name of Registered Agent
205 Hampton Street
Current Mailing Address
Stoneville NC 27048
City
State
Phone: Office # 336-552-6402
Zip
crakestrawl [e-mail]
E-mail Address
205 Hampton Street
Current Street Address
Stoneville NC 27048
City State Zip
Mobile # [phone]
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:
N/A
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
N/A
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.
Charles Rakestraw
Type or print name
("� Cw-Uza�
Signature
Member Manager
Title or Authority
9/30/22
Date
l_�-� cam• ��W� a Notary Public of the County of
State of North Carolina, hereby certify that (24'-M%j 1V appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this ,nL 'day of n b , 20 UU
KELLIE S. BROWN
— "I X ?OF�
NOTARY PUBLIC Notary
Rocf� 05am County, North Carolina
Nly Commission Expires 01 /1412024 My commission expires