NCC231841_FRO Submitted_20230614

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 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: 4545 High Point Road
2. Location of land-disturbing activity: County: Forsyth City or Township: Kernersville
Highway/Street: Old Greensboro Road Latitude:36.0352 Longitude.80.2708
3. Approximate date land-disturbing activity will commence: 12/1/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Mass Grading
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 7.80 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: David Smith E-mail Address: [e-mail]
Phone: Office#: 336-817-8671 Mobile#: N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Smith and Jenninghs Properties, LLC 336-817-8671
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
1020 Hedgecock Road 1020 Hedgecock Road
High Point NC 27265 High Point NC 27265
City State Zip City State Zip
10. Deed Book No's: DB 3624 PG 273
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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).
2.
Smith and Jennings Properties, LLC [e-mail]
Company Name E-mail Address
Current Mailing Address Current Street Address
1020 Hedgecock Road 1020 Hedcock Road
High Point NC 27265 High Point NC 27265
City State Zip City State Zip
Phone: Office# 336-817-8671 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:
5i-ri-if A et c1 T rirliit3I Trc eii(CJ f LLC day 1 d @ S•Y, i717 a� J,je ril toS. (cam,
Name of Registered Agent E-mail Address
loao ,t-leet7eCock tJ lo..,?G 1-fc1yt(ccI tI
Current Mailing Address Current Street Address
Pi3h Pent h( ,77a?65-- At19A Prrn1- NC d?‘"Z6S
City State Zip City State Zip
Phone: Office# 3 36 - •(_7 -86 7 f Mobile#
PA#nct 5r-1i1l1
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)
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(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��11 information provided herein.
C /harie5 51, /((1 v i1er
Type or print name Title or Authority
GG ( 6 /d 0,2 T
Signature Date
I,ifie reSP rr br- s - , a Notary Public of the County of 6c,,i 1 -c)
State of North Carolina, hereby certify that Charles f v i c Sc-;"‘"K appeared personally
before me this day and being duly sworn acknowledgedckn that the above form was executed by him/her.
Witness my hand and notarial seal, this "I day of u,n.e_ , 20 a3
��,• B-_ Notary
Seal ; \A O T,q '.
c ; �� ; My commission expires c?-- tS-
06,
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