NCC232372_FRO Submitted_20230809

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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Trinity Meadows
2. Location of land-disturbing activity: County Randolph City or Township Trinity
Highway/Street Welborn Road Latitude 35.8630 Longitude -80.0336
3. Approximate date land-disturbing activity will commence: February, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 67.3 AC +/-
6. Amount of fee enclosed: $ 4,420.00
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Sandy Cline E-mail Address digger6296aol.com
Telephone Cell# [phone] Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Keystone Group, Inc. [phone]
Name Telephone Fax Number
3708 Alliance Drive
Current Mailing Address Current Street Address
Greensboro NC 27407
City State Zip City State Zip
10. Deed Book No. 2753 Page No. 1955 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Keystone Group, Inc. [e-mail]
Name E-mail Address
3708 Alliance Drive
Current Mailing Address Current Street Address
Greensboro NC 27407
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a)If the Financially Responsible party is not a resident of North Carolina give name and street address
of a North Carolina agent.
Name
Mailing Address Street Address
City State Zip City State Zip
Telephone Telephone
(b)If the Financially Responsible Party is a Partnership or other person engaging in business under
an
assumed name, attach a copy of the certificate of assumed name. It the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent.
Name of Registered Agent
Mailing Address Street Address
City State Zip City State Zip
Telephone Telephone
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 or
his attorney-in-fact or if not an individual by an officer,director. partner, or registered agent with
authority to execute instruments for the financially responsible person). I agree to provide corrected
information should there be any change in the information provided herein.
Scott Wallace President
Type or print name Title or Authority
Signature Date
I/2/Yl ///y4o z z
I, G T€#ii pbe Aio//Q a Notary Public of the County of au 1 i-r0 2P
State of North Carolina, hereby certify that 1A.1 • S c o-r-r iiJA-u.P-c_E
appeared personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness m h d iAk i4�Fseal, 's I 2-- day of 57414 u acz'f ,20 ZZ
NOTARY PUBLIC
GUILFOTD COUNTY, NC )
Seommisston Expires 12-LZZ Notary/
My commission expires i 2/74 zZ