NCC233255_FRO Submitted_20231102

C Department of Environmental nt of y
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Recpjv(+d
SEDIMENTATION POLLUTION CONTROL ACT BAN ' i
EXPRESS PERMITTING OPTION a
No person may initiate any land-disturbing activity on one or more acres as covered by the Alcilieloee ibis 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. F , -- zo23—OIr
1. Project Name Ogden School Road Subdivision
2. Location of land-disturbing activity: County Forsyth City or Township Kernersville
Highway/StreetOgden School Road Latitude(decimal degrees) 36.059797 Longitude(decimal degrees)-80.078023
3. Approximate date land-disturbing activity will commence:01/15/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):17.9
6. Amount of fee enclosed 1800 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed ® No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Milt Rhodes E-mail Address miltardenhomes.com
Phone: Office# 336-659-9503 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
PM development, LLC 336-659-9503 N/A
Name Phone: Office# Mobile#
412 N.Marshall Street Same
Current Mailing Address Current Street Address
Winston Salem NC 27101 Same Same Same
City State Zip City State Zip
10. Deed Book No.2620 Page No.3226 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).
PM Development,LLC milt(o�ardenhomes.com
Company Name E-mail Address
412 N. Marshall Street Same
Current Mailing Address Current Street Address
Winston Salem NC 27101 Same Same Same
City State Zip City State Zip
Phone: Office# 336-659-9503 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:
Milt Rhodes miltardenhomes.com
Name of Registered Agent E-mail Address
412 N.Marshall Street Same
Current Mailing Address Current Street Address
Winston Salem NC 27101 Same Same Same
City State Zip City State Zip
Phone: Office# 336-659-9503 Mobile#
Milt Rhodes
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
FEI Consulting bnesomAfeiconsultinq.com
Engineering firm or other consultant E-mail Address
Brent Nesom 336-544-6421 NA
Individual contact person (type or print) Phone: Office# Mobile#
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.
Milt Rhodes Agent
Type or rint name Title or Authority
71 3
i atu Date
I, Svuannt IU` vuo a550Y1 , a Notary Public of the County of GlActrd
State of North Carolina, hereby certify that !WA' 'RAOck 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 5 day of --6-190Yt J04 , 20 23
7LA/r4V W(.,1,, A493 tl/0
Notar
Seal My commission expires 1,1-'65 ' 2021
SUZANNE M THOMASSON
NOTARY PUBLIC
GUILFORD COUNTY,NC
My Commission ExpNe$ ,11-'OS—2021