NCC230930_FRO Submitted_20230428

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM (REV 21 April 2022)
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 Streamside at Bush Hill
2. Location of land-disturbing activity: County_Randolph_City or Township Archdale
Highway/Street_4805 Archdale Rd Latitude 35.8897_Longitude -79.9606
3. Approximate date land-disturbing activity will commence: December 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Attached_Residential_
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 36.0 Ac
6. Amount of fee enclosed: $ . 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. Enclosed X No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Wesley Scott Wallace E-mail Address [e-mail]
Phone: Office# 336-856-0111 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
_Keystone Group Inc _336-856-0111
Name Phone: Office# Mobile#
_3708 Alliance Dr
Current Mailing Address Current Street Address
_Greensboro NC 27370
City State Zip City State Zip
10. Deed Book No._2798 Page No._1760_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.)lf the company is a sole proprietorship or if the
landowner(s)is an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies).
Keystone Group Inc [e-mail]
Company Name E-mail Address
_3708 Alliance Dr
Current Mailing Address Current Street Address
_Greensboro NC_ 27407
City State Zip City State Zip
Phone: Office# 336-856-0111 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 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.
W LC A.C.6- re 51 o e r
Type or print name Title or Authority
-pres,ee 4. 312-7/Zo7-3
Signature Date
I, L-- Ye im Pits. WQ I I a,e , a Notary Public of the County of i 1-- 0 /2
State of North Carolina, hereby certify that tAl. �'fi wtkA-A- appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him/her. �,�7
Witness my hand and notarial seal, this Z3 day of �`"!a Y e-A , 20 23
L TEMPLE WALLACE / yA®
NOTARY PUBLIC
GUILFORD COUNTY,NC Notary
My Commission Expires 11--7`'7-1
Z"�My commission expires - �-�