NCC233634_FRO Submitted_20231208

Check if this project is ARPA-funded
Attach a copy of the Letter of Intent to Fund
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 DME Racing Building Site
'If this project involves American Rescue Plan Act (ARRA) 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 Davie City or Township Mocksville
Highway/Street corner Milling and Bethel Latitude(decimal degrees)35.90286Longitude)decimal degrees)80.53714
3. Approximate date land-disturbing activity will commence: 10/13/23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2 acres
6. Amount of fee enclosed: $200.00 . 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 Dimey Eddinger E-mail Address [e-mail]
Phone: Office# 336-785-4845 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DME Elite Properties LLC 336-785-4845 336-345-2688
Name Phone: Office# Mobile#
2260 Old Salisbury Rd
Current Mailing Address Current Street Address
Winston-Salem, NC 27127
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.