NCC233759_FRO Submitted_20231220

Check if this project is ARPA-funded Ti
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: Midnight Run
'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: Davidson City or Township: Lexington
Highway/Street: City Lake Road Latitude(decimai degrees): 35.862275 Longitude(decimal degrees): 80.217922
3. Approximate date land-disturbing activity will commence: 1/1/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.74 acres
6. Amount of fee enclosed: $800. 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 Z No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name :Justin Nifong E-mail Address:justinPlycoproperties.com
Phone: Office#: 704-562-5012 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Erik Kelly 336-207-8877
Name Phone: Office # Mobile#
284 J A Tysinger Road 284 J A Tysinger Road
Current Mailing Address Current Street Address =�
Thomasville, NC 27360 Thomasville, NC 27360
City State Zip City State Zip
10. Deed Book No. 1800 Page No. 1622 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).
Hazy Skies, LLC justinPlycoproperties.com
Company Name E-mail Address
1340 Creekshire Way, Suite 210 1340 Creekshire Way, Suite 210
Current Mailing Address Current Street Address
Winston-Salem, NC 27107 Winston-Salem, NC 27107
City State Zip City State Zip
Phone: Office#704-562-5012 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:
Justin Nifonci [e-mail]
Name of Registered Agent E-mail Address
3409 Union Grove Road 3409 Union Grove Road
Current Mailing Address Current Street Address
Winston-Salem, NC 27127-9212 Winston-Salem, NC 27127-9212
City State Zip City State Zip
Phone: Office#: 336-793-8710 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.
Nt r71146Ivla�
Type or print name Title or A hority
Sig at r '01-A4 -1) i(
Date
I, C''' la2/ `t e_ j,`f acso, , a Notary Public of the County of -PAU/ O/1
State of North Carolina, hereby certify that 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 2-2 day of /VDU ntih-cr , 20 -2-3
CHARMAINE Notary
Notar �ACKSON
Y tstfc, North Carolina
Davidson County My commission expires 3j--`�-
MY Commission Expires
March 14,�028
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