NCC232477_FRO Submitted_20230816

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 Sanctuary at Southgate
2. Location of land-disturbing activity: County Union City or Township Indian Trail
Poplin Road 35.0896 -80.5911
Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 12/01/2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 95.9 ac
($5,655 previously
6. Amount of fee enclosed: $900 paid for 87 ac, . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name George Bartley Carroll E-mail [e-mail]
Phone: Office# 704-620-7373 Mobile# n/a
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Li,Yumei Poplin Heights Revocable Trust Go Walton North Carolina,LLG 703-677-9068 n/a
Name Phone: Office# Mobile#
14614 N. Kierland Blvd, Suite 120 14614 N. Kierland Blvd, Suite 120
Current Mailing Address Current Street Address
Scottsdale AZ 85254 Scottsdale AZ 85254
City State Zip City State Zip
10. Deed Book No.7657 Page No.0419 Provide a copy of the most current deed.
(PID #07021007D, additional parcels listed on continuation sheet)

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).
D.R. Horton, Inc./George Bartley Carroll [e-mail]
Company Name E-mail Address
8025 Arrowridge Blvd 8025 Arrowridge Blvd
Current Mailing Address Current Street Address
Charlotte NC 28273 Charlotte NC 28273
City State Zip City State Zip
Phone: Office# 704-620-7373 Mobile# n/a
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mire Lake Ct Ste 200 160 Mire Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office# 919-821-7139 Mobile# n/a
Thomas Montano
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:
n/a
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.
n/a
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.
George Bartley Carroll Division NPDES Manager
Type or print name Title or Authority
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Sign ture Date
1, Lc&-F(/1/ OR E EC/H , a Notary Public of the County of /VteCic lev b4-ke9
State of North Carolina, hereby certify that use � r+Iei C&rrci l i appeared personally
before me this day and being duly sworn acknowl dged that the above form was executed by him/her.
Witness my hand and notarial seal, this tc day of Abvexvilae,r , 20 2 a
LOGAN F. CREECN
Notary Public. North Carolina
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