NCC231204_FRO Submitted_20230425

Check if this project is ARPA-funded
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 City of
Archdale ACE Integrated Stormwater Management Program. Submit the completed form and current deed to
the appropriate personnel. (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 508 English Farm Rd - Phase 1
'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 Randolph City or Township Archdale
Highway/Street Trindale Rd Latitude(decimaIdegrees) 35.9060 Longitude(decimaidegrees) 78.9802
3. Approximate date land-disturbing activity will commence: April 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 50.00
6. Amount of fee enclosed: $ 0 (paid at TRC) . The application fee is defined in the published City
of Archdale fee structure which is typically$0 when a Technical Review Committee (TRC) evaluation is
required. Checks should be addressed to City of Archdale
7. Has an erosion and sediment control plan been filed? Yes 1' Enclosed 7 No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Eric Dischinger [e-mail]
Name E-mail Address __
Phone: Office# 336 317. 395 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DESCO EF LLC 336.275.7626
Name Phone: Office# Mobile#
804 Green Valley Rd Suite 200 804 Green Valley Rd Suite 200
Current Mailing Address Current Street Address
Greensboro, NC 27408 Greensboro NC 27408
City State Zip City State Zip
10. Deed Book No. 2830 Page No. 465-477 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 propnetorship or if the landowner(s)is
an indivldual(s), the name(s) of the owner(s)may be listed as the financially responsible party(ies).
DESCO EF, LLC dsullivan@descoinvest corn
Company Name E-mail Address
804 Green Valley Rd Suite 200 804 Green Valley Rd Suite 200
Current Mailing Address Current Street Address
Greensboro NC 27408 Greensboro NC 27408
City State Zip City State Zip
Phone Office# 919 961 3690 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:
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 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.
Atmo
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Type or print name l/ Title or Authority
�-, /10/7,2
Signature Date
I, JY)c44C6 �t q , a Notary Public of the County of Mecelem
State of North Carolina, hereby certify that 's C- l SC.);Y\C4PJ appeared personally
before me this day and being duly sworn acknowledged that the Wove form was executed by him/her.
Witness my hand and notarial seal, this I04-k. day of Apr? I , 20 2 3
Orki CA_ C)fLev,
CYNTHIA K JUDA Nota
Notary Public, North Carolina )
Meatenbur County Li 25/2Q2'1
tYil ° My commission expires f•1 . rtny Commission Expires
April 29,2027

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 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 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 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.

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 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 Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#