NCC231469_FRO Submitted_20230515

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, 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 N/A in the blank.)
Part A.
1. Project Name Kintegra Health New Medical/Dental Clinc-Bessemer City, NC
'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 Wafer Infrastructure(DWl.
2. Location of land-disturbing activity: County Gaston City or Township City of Bessemer City
Highway/Street 308 E.Virgina Ave Latitude(decimal degreesl LongitUde(decimal degrees)
3. Approximate date land-disturbing activity will commence: Less than 3 acres
4. Purpose of development(residential,commercial, industrial, institutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): Less than 3 acres
6. Amount of fee enclosed: $ $300.00 . 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 IX Enclosed E( No ❑
8. Person to^^ contact should erosion and sediment control issues arise during land-disturbing activity:
Name (,/,g14taL (-fqv_ E-mail Address fat.+ttsaHA.mca-Tft2GMAIL.ecr."
Phone: Office# 33I -Za2-7280 Mobile#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
6AE-T ) FAMILY HEAL-rW 7 9 —$74f —faoo
Name Sfsts viCe5 +NG. Phone: Office# Mobile#
ZQc. E. Seen Avg. 2000 0. SEcx►.lo a.a
Current Mailing Address Current Street Address
SA GA 28052 6,4sTri.MA GA ZistoS2
City State Zip City State Zip
10. Deed Book No. E40 _Page No, ZZG.S Provide a copy of the most current deed.

•Qilli:cl(y(I .".) `rvvll( ale iiiic iii I, ll leIli(-t,i Joibilt(! :iiv ty (L.� i,�F, 1)t 01 owit .ni iAIF+ !i-;i
,n 3311 ir.,I?vi ni ,1(i Iniltic 33 Un c((i(ll(lp Il.ic! ft ) Illhc_ c;;lll/) '-i 1.,-; :0k--] dNgioini l:.Ib) i,=;
II,iii+riVid11]/(S), i/cO I7diii .(S) !if time O is '(,) /he I cICl C1�����I(3po, ible
C,..01vMdt-irry 1-teAL-T'irl Mst<it,I..E•STAD RI = ` . CfraC
(;01itj3 iuy (t ili(t ?f C � ( mail lb.ldress
ZOOE . SEcc Ate. ZOO � • �j��r� �a.�.
(;Ilri'eilIt ( uio,-)rlt P,treni !Vd11ici.c
�AS fq ('J Z$052 GAS e+ NJC 015052.
city ;tale it) City State Zip
_ I ,
Phone: (-Office: 704 " 079- 149 - Ti -so So
l`,.lote. l ill( l-nia.ncicilly 1t(.i.poirslflc. Pally is: not the uvWnl r of the land to he disturbed, in(_aude with this form
the I r(_lowner's signed and (' 'ted Writtci I consent for the applicant to 5(Ibnilt a draft I fic ion and ',edinientation
control t;lccn and io condu( t ttfe anticipated land disturbing activity
2. (a) Tithe Financially Responsible Tarty in a domestic company regic,tered on the r!C. Sectc;taly (;7l `,gate
business.s registry, give name u d street address of the Registered Agenl:
Nµv‘vJu try 1-10.4terH s
Name of F/vt istei( d Agent 5.rma, Addicr.s
Zoo e . an aa„ . ,2ec, . 5a-c
( urgent i iailing Address dre Current 'Sheet Adclrer,s
-z3 2 2icoS-2.
City State zii, city Niche Zip
70 - E5-7(( - Atiq
Phone: Office -8714 " fCtr __-- Mobile /. 70L( -s$So
1-4A24C sevLsr---Arp. stc.i ..STigc
Name of Individual to Contact(if Regi:toed Agent i-, a company)
(b) ii the 1 inrincially Respoueihlcc tarty is not a resident of North Cal-Nina, c;ive n..ine ,n_i :;fier i ccidre--ss
(;f the designated North t,arolina agent who i:- registered oil Tile: kit, ..;ecr( ic.ry of State hush i:;.r, registry:
st
IVIcurle in Registered Agent t_ moil Adoies;--;
Current ent Mailing /I,odres.(. Current Ilrent Street Address
City State City Sate zip
Phone: Office tit, Mobile;1
1
I larne of Individual to ( nutti,ci (n Registered Agent i; a coral,any)

(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.
Kintegra Health
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.
Mark T. Skillestad Manager of Contracts and Physical Assets
\print name Title or Authority
05-03-2023
Signs re ' ' �'� Date
I, �c.� � c, ����� a NotaryPublic of the Countyof �"a(;� uf`1
Tr �,r��mil, I `�
State of North Carolina,hereby certify that��cyr k- Skip.�l PS-L0.2 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 rY\0_9 , 20 X3
o c.., C c0—L-'U. c ),(
Notary
TRACY DAt ALE FAILE
NOTARYPUBLIC My commission expires �l.°1 as..)a G
Gaston County
North Caroli a .`� .
My Commission Expires 3�

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1:0t01H ; (.7 itit!!!!!p Nor /lu'itti,4 it)11;;'i it 11ii(101,11,4„-",,r;
(it
Mio;-)11c,.11
,i\ddresR Gurront Addre.,,-;;;
City '.3tate, Pp City State
Deed (=look hli). rope No. Provide;=3 copy of the inwil otirrent dood,
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.01
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Idomiet `.?!
1\l,hrne Phone: Offic:e Mobile 711!
Cullen( fftilincyAddress Current Street Ad(ires.--.;
Cily State ;?ip City Zip
Deed Hook No, No. provide mpy of the most urn not deed,
1
Larulowlip,,r4
Nome Phone; Office II Mobile tt
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Curront Meiling Address Current Street Addrest;
City Stati Zip City Ctio Zip
Deed I took! No, No. Provide Li copy of the most current deed,
1_.andowi Record:
Name Phone: Office II Mobile It
Current R4alling Address Ciirrent Street Address
City State Zip City State Zip
Deed Bock No, ['ago Ni Provide P, copy oi the most current deed.

Continued horn Item i in Part C of the l'inancial Responsibility/Ownership t orm for multiple parties.
/Vlach copies of this page as needed to list all thianoially responsible parties
AtA GrzAcAt.x5 1-44.40,6 eA,AGraitztcm,c.,.
Company 2 Name Email Address
S' RA Not 014g 12AtiAsLem. Rc>.
Current Mailing Address Current Street Address
2.V0 G
rac - rcrry Kic zit:ohsI 4srir 2.71s
City State Zip City State Zip
Phone: Office# 704 — 060-SV23 Mobile A
Company 3 Name Email Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office# Mobile#
i -
Company LI Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile ft
Company 5 Name Email Address
Current Mailing Address Current Street Address
City State Zip City State Zlp
Phone: Office# Mobile#