NCC231099_FRO Submitted_20230419

Check if this project is ARPA-funded
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
i 4- person may initiate any land -disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 NIA in the blank.)
Part A.
1, ProjectNameClementine Ridge Subdivision
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land -disturbing activity: County Davidson City or Township Lexington
Lamb Rd 35.768-80.386
HighwaylStreet LatitudetaeGmai degrees) Longitude(deumai degrees)
3. Approximate date land -disturbing activity will commence:4/4/23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas).2.3
6. Amount of fee enclosed: $300 . 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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Daniel Everhart [e-mail]
Phone: Office # 336-596-1753 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
PoP Homes - GSO LLC 336-596-1753 336-596-1753
Name Phone: Office # Mobile #
464 Rickard Drive 464 Rickard Drive
Current Mailing Address Current Street Address
Winston Salem NC 27101 Winston Salem NC 27101
City State Zip City State Zip
10. Deed Book No. 2449 Page No. 1 272 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).
POP Homes - GSO LLC
Company Name
464 Rickard Drive
Current Mailing Address
Winston Salem NC 27101
City State Zip
Phone: office # 336-596-1753
[e-mail]
E-mail Address
464 Rickard Drive
Current Street Address
Winston Salem NC 27101
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:
Emiiy J. Meister
Name of Registered Agent
6323 North Elm Street Suite 200
Current Mailing Address
Greensboro NC 27455
City
State Zip
Phone office # 336-378-1899
[e-mail]
E-mail Address
6323 North Elm Street Suite 200
Current Street Address
Greensboro NC 27455
City
Mobile #
State Zip
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 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.
Type or print na Title or Authority
Signature Date
I, Lor-t a Notary Public of the County of G UL" 1-G21-rJ—
State of North Carolina, hereby certify that o ol os l 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 r-t L l 20 -23
Lod Oates q��- k
NOTARY PUBLIC Notary
Guilford County, NC
My Commission Expires October 20, 2025 My commission expires j O - a 0 -a _

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
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 3 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 4 of Record:
Phone: Office #
Current Street Address
Mobile #
Zip City State Zip
Page No. Provide a copy of the most current deed.
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 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 mast current deed.

Continued from Item t in Part 8 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zlp
Phone Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip