NCC240630_FRO Submitted_20240308

FINANCIAL RESPO NSIBILITY/O W NERSHIP FO RM
SEDIM ENTATIO N PO LLUTIO NCO NTRO LACT
No person m ay initiate any land-disturbing activity on one or m cre acres as covered by the Act, including any
activity under a corn m m plan of developm ent of this size as covered by the NCG 01 perm t, before this form
and an acceptable erosion and sedim entation control plan have been corn lieted and approved by the Land
Q uwlity Section, N.C. Departm ait of Environm eital Quality. Subm t the corn Meted form to the appropriate
Regional O fice. (Please type or print and, if the question is not applicable or the a-m al address or phone
num her is unavailable, place N/A in the blank.)
Part A.
1. Project Nam a Phoenix Cinders
*If this project involves Am a-ican Rescue Plan Act(ARPA)funds, list the Project Nam ebelow under which
you applied for funding through the Division of Water Infrastructure (DWI).
Is Project ARPA Funded ARPA Project Nam e ARPA Project#
No
2. Location of land-disturbing activity: County: Rockingham C ity or Township: M alison
Highway/Street: 4501 NC HWY 704 Latitude: 36.376600 Longitude:-79.945201
3. A pproxim de date land-disturbing activity will corn m eice: 3/1/2024
4. P urpose of developm ait (residential, corn m ecial, industrial, institutional, etc.): Residential
5. T otal acreage disturbed or uncovered (including off-site borrow and waste areas): 11.00
6. T he application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount (Exam ile: 8.10-acre application fee is $900).
7. H as an erosion and sedim ent control plan been filed? No
8. P erson to contact should erosion and sedim ent control issues arise during land-disturbing activity:
N am a Ali Am a- E -m al Address: [e-mail]
Phone: [phone] Mo bile: 336-944-9000
9. L andowner(s)of Record:
Landow ner(s) of Record
Name Email Business Phone Mobile Phone
Ali Am a- [e-mail] 3 36-944-9000 3 36-944-9000
Physical Address M sling Address
Street 1 City State Zip Street 1 City State Zip
201 N. M u-row G eensboro NC 27402 201 N. M u'row G eensboro NC 27402
Blvd, Suite 1533 Blvd, Suite 1533

Part B.
1. Com pany(ies) who are financially responsible for the land-disturbing activity (Provide a corn prehensive 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
nam e(s) of the owner(s)may be listed as the financially responsible party(ies).
Primary Financially Responsible Party
Company Name Email Business Phone Mcbile Phone
Ali Am er ali©sendphoenix.com 3 36-944-9000 3 36-944-9000
Physical Address M sling Address
Street 1 City State Zip Street 1 City State Zip
201 N. M u-row G eensboro NC 27402 201 N. M u-row G eensboro NC 27402
Blvd, Suite 1533 Blvd, Suite 1533
Additional Financially Responsible Parties _
Company Name Email Business Phone Mcbile Phone
Ali Am e--Am e-Estate Holdings, LLC [e-mail] 3 369449000 3 369449000
Physical Address M sling Address
Street 1 I City I State Zip Street 1 I City I State Zip
201 N. M u-row G eensboro NC 27402 201 N. M mow G eens NC 27402
Blvd, Suite 1533 Blvd, Suite 1533
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 subm I a draft erosion and sedim eitation control
plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domes tic company registered on the NC Secretary of State
business registry, give nam e and street address of the Registered Agent:
Registered Agent Information
Name Email Business Phone Mcbile Phone
Physical Address M sling Address
Street 1 City State Zip Street 1 City State Zip
(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:
North Carolina Agent Information
Name Email Business Phone Mcbile Phone
Physical Address M sling Address
Street 1 City State Zip Street 1 City State Zip
Engineering/Consulting Firm Information _
Name Email Business Phone Mcbile Phone
Ravindra Bissram rbissram @eiconsulting.com 3 365446426 3 363373651
Physical Address M sling Address
Street 1 City State Zip Street 1 I City I State Zip
8518 Triad Drive Colfax NC 27235 8518 Triad Drive Colfax NC 27235

Additional Details
1. Stream Classification: WS-V: Water Supply V
2. Was Express Review Requested: No
The above inform ation is true and correct to the best of m y knowledge and belief and was provided
by m eunder oath. (This form m Lst 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 instrum efts for the Financially Responsible Party). I agree to provide
corrected inform Aion should there be any change in the inform Aion provided herein.