NCC232602_FRO Submitted_20230829

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 Wexford - Phases 3-5
*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 Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Alamance City or Township Elon
Highway/Street:Gibsonvil le-Ossipee Rd Latitude(decimal degrees) 36.122 Longitude(decimal degrees) -79.526
3. Approximate date land-disturbing activity will commence: Spring 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 35.00
6. Amount of fee enclosed: $ 3,500.00 . 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 X No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brad Dyer E-mail Address bdver(a�eastwoodhomes.com
Phone: Office# 980-721-0919 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Wexford 199, LLC 704-399-4663
Name Phone: Office# Mobile#
2857 Westport Road same
Current Mailing Address Current Street Address
Charlotte, NC 28208 same
City State Zip City State Zip
10. Deed Book No. 4360 Page No. 706-710 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.)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).
Joe Polite—MTS TRI, LLC 1politeeastwoodhomes.com _
Company Name E-mail Address
3980 Premier Drive, Suite 120 same
Current Mailing Address Current Street Address
High Point NC 27265 same
City State Zip City State Zip
Phone: Office# 704-574-7877 Mobile# [phone]
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:
Eastwood Homes—Clark J Stewart icstewart(c�eastwoodhomes.com
Name of Registered Agent E-mail Address
2857 Westport Road same _
Current Mailing Address Current Street Address
Charlotte NC 28208 same
City State Zip City State Zip
Phone: Office# 704-574-7877 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.
C1/O/i( Sf ,Q,71 lewd ev ��n Bd
Type or rint a Title or Authority
nature Date
I, 4ftN\JV'\ I 'l
a Notary Public of the County of n('a-VAnlDW`� `J
State of North Carolina, hereby certify that J • CA V /V-VOI Y ! 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 Zfj' day of IVWli , 20 1V.)
Kaitlyn Salley
NOTARY PUBLIC
Mecklenburg County
North Carolina N tary AritrY\
My Commi ion"xpues April,27,2025
My commission
expires 4 -1 L3 Continued from Items 9 & 10 in Part A of the Financial
Res onsibillt /Ownershi Form for p y p o multiple owners. Attach copies of this page as needed to list all
landowners.
Landowner 2 of Record:

Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No._ Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record•
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. _ Page No. Provide a copy of the most current deed.
Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.

Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#