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Home My WebLink AboutNCC233011_FRO Submitted_20231009 Check if this proj N CAS,+, a tm nt �hl��r rrr��'u Attach a copy of the Letter of Intepert+ued FINANCIAL RESPONSIBILITY/OWNERSHIP FORM AUG 0 3 2023 SEDIMENTATION POLLUTION CONTROL ACT Wincton.7Hrmi No person may initiate any land-disturbing activity on one or more acres as covered by therAbt,ciii lu6ing any activity under a common plan of development of this size as covered by the NCGO1 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 Holt Campus at Flynwood and Main *If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Forsyth City or Township Kernersville 0 Main St. 36°8'14.60"N -80°3'7.34"W Highway/Street Latitude(decimal degrees) Longitude(decimal degrees) 3. Approximate date land-disturbing activity will commence: 10/1/20 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19.2 6. Amount of fee enclosed: $2,000.00 . 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 El Enclosed ❑ No 0 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Michael P. Criscuolo E-mail Addressmichaelc@holtgroup.com Phone: office# Mobile# 336-549-8172 9. Landowner(s) of Record (attach accompanied page to list additional owners): CMC Jomada Holdings, LLC 336-549-8172 Name Phone: Office# Mobile# PO Box 168 Current Mailing Address Current Street Address Oak Ridge NC 27310 City State Zip City State Zip Page No.3291 10. Deed Book No.3175 Provide a copy of the most current deed. c,%jitr i ''ate"• ;mow"""w* .� ��+ �,-- r -var eCt 5 �W- ..�. �"��'r�'.�fi7 "k� h�, ��f:'��.�4.. •�—� {� �i��#1r �r : a�r�-��'�- - ��7,ft5 `fi�m .. F:n...w nr�`'iYsI��" ,�_ "�1- ,+�S Check if this projeegagge�U H#'y Attach a copy of the Letter of Inteietpec' FINANCIAL RESPONSIBILITY/OWNERSHIP FORM AUG 0 3 2023 SEDIMENTATION POLLUTION CONTROL ACT Witrtnn•-S'!m No person may initiate any land-disturbing activity on one or more acres as covered by therAd,clflcluaii any activity under a common plan of development of this size as covered by the NCGO1 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 Holt Campus at Flynwood and Main *If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Forsyth City or Township Kernersville O Main St. 36°8'14.60"N -80°3'7.34"W Highway/Street Latitude(decimal degrees) Long itude(decimal degrees) 3. Approximate date land-disturbing activity will commence: 10/1/20 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19.2 6. Amount of fee enclosed: $2'000.00 . 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 Michael P. Criscuolo E-mail Addressmichaelc@holtgroup.com Phone: Office# Mobile# 336-549-8172 9. Landowner(s) of Record (attach accompanied page to list additional owners): CMC Jomada Holdings, LLC 336-549-8172 Name Phone: Office# Mobile# PO Box 168 Current Mailing Address Current Street Address Oak Ridge NC 27310 City State Zip City State Zip Page No.3291 10. Deed Book No.3175 Provide a copy of the most current deed. I, .. V 3.1I4i ::.: '1_,t'I..;i'.:IC(1 .-'.•..: -P..:'..' It '..ii.it‘ • .. . , . , . _ - . .• _ . _ . _ __ _ - • P I , . 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IJ .. mi ... ..... ..1.1 mP----- "--- r---.--,j• i-Fa u" 1 •mar N. m.•a a r ,• au - •-1-1.• r a r • • J&ma a ailmaiwairamamarma •-a 1.1 -„ -ma II Ai -I r a.-aro -a• - r- -I -.1 -1.-a •i. r -mail-la aimaniarillamln ,- 111-1111i9MMINI - '1N IIM•- Mir llr VI- IllE •nlell1MMIJIMInLIMI•Milil-•-" -- '•_. iiri..qi 7 'Al =1 9M9Ne—4--m- llINMEMINIMANM. , • •, . , • E. i . .. ,-. - -,-' -_. ---".---;" ,,,,-. . -- -- -, ,,.- . —•..-..- .-., -,,.'--:'-. i",;'..''_,••.,; —,,,''', .-,'':,::.,".,1-.::..:''''".'.:".. Ff..:..'..,'-;.--,,J..., ,...'.q'-.:.'.,....,?;s4 7-7'. ';'-:'",,1:•7'.:..•'-..:',',.'.:,' .-1:.,..-..,.'-' :.:2':-.f:.',-:7._.',..4'...,.7-:',, ;,:.:...,,:',._:_.,:,.."- i•TIV' . . -. 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). CMC Jomada Holdings, LLC michaelc@holtgroup.com Company Name E-mail Address PO Box 168 Current Mailing Address Current Street Address Oak Ridge NC 27310 City State Zip City State Zip Phone: Office# Mobile#336-549-8172 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: Scott K. Tippett Name of Registered Agent E-mail Address 300 N Green St. Suite 200 Current Mailing Address Current Street Address Greensboro NC 27401 City State Zip City State Zip Phone: Office# 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) F JP' 4 T E . ■LT L ■■L■ J L • _fir _ fI- .4Y1-1 ~ ,y 'l -_- _ _ — L _�_' _ _ _ ___ •• IL- - - - -- - — - -- --._— _y 2 -- _- - - _ _ - V - - - - C - _. - - .— IP Cam■®ma- ■ - --m1 -— - 7—r■- - - - - - - ■ - T - - - ■ - -■7 - -r- as - _ - - -- ... - - --- --- - - - - - r -- - —`. '''' ____ 111____Sf�rrriL_Yira Nam'ia..in-:.w.. ".Ysmril — -_- -_—--= - ■i Namei iimis-mimIlm Immi■■ ■N. mi. - T __ _ _ _ _ ___ - - - __ - _ I NM■ ■ ,- •,..� a a. -. . wu gsuY+. '1 ;r:_r if r- -r r -:i ;; V ,7 =r 7c _•r,:":'. "', ,tt r'- e.' .Y -'- r --'1 (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. Michael P. Criscuolo Manager Type 'nt nam/,ee Title or Authority 7.?//-2 ? Sign ure Date /— u 6& // R e . V. , R,r;ueT�iu , a Notary Public of the County of f< Ioc/1iitione4 IA-- State of North Carolina, hereby certify that /i e_ht4-e_I P. CRi sC€v/a appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her. sr- Witness my hand and notarial seal, this 2 f day of _I V,u E , 20 Z3 ,o('‘,‘. ..''''4''K9',7,.. .,..(:).Lt_t_. V. Va_tiA1v, \ V at- ';Notary �l -�'.... 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