NCC224212_FRO Submitted_20221229

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 th ny Townes
2. Location of land -disturbing activity: CountvAlamance City or TownshipGraham
South Main Street (NC Hwy 87) 36.0401-79.3934
Highway/Street Latltude(decimaldegvees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: December 13 2022 _
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Res�den it d —
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):8.0 acres
6. Amount of fee enclosed: $800.00 . 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 ® No
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name itch Murphy E-mail [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Clay Pigeon Properfies, LLC (1 ) 730-0 84
Name J Phone: Office #
PO Box 90427
10
Current Mailing Address Current Street Address
Raleigh NC 27676
City State Zip City
65
Deed Book No.41 Page No. 37
4166 0071
State
Mobile #
Zip
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).
Clay -Pigeon -Properties, LLC
Company Name
PO Box 90427
Current Mailing Address
Raleigh NC 27676
City State Zip
Phone: Office #(919) 730-73
[e-mail]
E-mail Address
9220 Fairbanks Dr., Suite 220
Current Street Address
Raleigh NC 27613
City State Zip
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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 coley
of the Certificate of Assumed Name.
Company DBA Blame
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.
Mitch Murphy
Type or print name
Signa e
N11'an ing Member
Title or Authority
Date
1, � One;;h 14a :61 - f_ 0 ui�-f , , a Notary Public of the County of �01n ti l d n
State of North Carolina, hereby certify that I A Uf Vh:i 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 day of OCr}c% p„i 20 %?,
®`V\ KEl TH /j 01
tary
®� �0TAR
MycannissionDow _ My commission expires P —05 — 2 0 ?iS
1a5-2025
pU®L1� 4F
sue//SJ®,I cok �, l \o®

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:
Clay Pigeon Properties, LLC
(91 ) 730-0734
Name
Phone: Offiice # Mobile #
PO Box 90427
9220 Fairbanks Dr., Suite 220
Current Mailing Address
Current Street Address
Raleigh NC
27676
Raleigh NC 27613
City State
Zip
City State Zip
Deed Book No.4 1 65
Page No.0637 Provide a copy of the most current deed.
Landowner 3 of Record:
Clay Pigeon Properties, LLC
(19) 730-0734 _
Name
Phone: Office # Mobile #
PO Box 90427
9220 Fairbanks Dr., Suite 220
Current Mailing Address
Current Street Address
Raleigh NC
27676
Raleigh N"C 2761
City State
Zip
City State Zip
Deed Book No.41 66
Page No. 0071
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
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
Deed Book No. Page
Phone: Office #
Current Street Address
Zip City
Mobile #
State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
City State
Phone: Office #
Company 3 Name
Current Mailing Address
City State
Phone: Office #
Company 4 Name
Current Mailing Address
City State
Phone: Office #
Company 5 Name
E-mail Address
Current Street Address
Zip City State
Mobile #
E-mail Address
Current Street Address
Zip
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
State
Zip