NCC240702_FRO Submitted_20240319

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place N/A in the blank).
Part A:
1. Project Name: Keystone at James Landing,Phase 2
2. Location of land-disturbing activity: 5710&5711-5733 Ruffin Road
3. Approximate date land disturbing activity will be commenced: _ ' ' • Fj 3. 15i 2 o 24
4. Development type: Commercial_Industrial Institutional ME residential r SF residential
5. Approximate acreage of land to be disturbed: 19.6 acres+l-
6. Has an erosion and sediment control plan been filed? Yes ,r No
7. Landowner(s)of Record(attach pages to list additional owners):
Keystone Group,Inc. [phone] swallace(mgokeystone.com
Name Telephone Email
3708 Alliance Drive 3708 Alliance Drive
Current Mailing Address Current Physical Street Address
Greensboro NC 27407 Greensboro NC 27407
City State Zip City State Zip
8. Deed County: Guilford Book: Page:
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: W.Scott Wallace Telephone: [phone]
E-mail: [e-mail] Other:
Part B:
1. Company(ies)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive
list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship the name of the owner
or manager may be listed as the financially responsible party.
Keystone Group,Inc. [phone] [e-mail]
Name Telephone Email
3708 Alliance Drive 3708 Alliance Drive
Current Mailing Address Current Physical Street Address
Greensboro NC 27407 Greensboro NC 27407
City State Zip City State Zip

2. (a) If the Financially Responsible Party is not a resident of North Condina, give name and street address of the
designated North Carolina Agent:
Name Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed
name, attach a copy mf the Certificate of Assumed Name. |f the Financially Responsible Party iomCorporation,
give name and street address of the Registered Agent:
VV.Scott Wallace,President'Keystone Group,Inc. (336)856'0111 owaUowo@,gohwymbonw.opm
Name Telephone Email
37O8 Alliance Drive 3708 Alliance Drive
Current Mailing Address Current Physical Street Address
8newnybnru NC 27407 Gmenmhnm MC 27407
City State Zip City State Zip
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 or his attorney-
in-fact, 0rifnot an individual, by an officer, director, partner, or registered agent with the authority to execute
inntrurnentafor the FinanoiaUyResponsible Person). I agree to provide corrected infonnaUon 'hou|dtheny
ba any change in the information provided herein.
VV.Scott Wallace President'Keystone Group,Inc.
Type ur print name Title orAuthority
4V
Signature Date
�
k*/« / /�/e . a Notary Public of the County of / Lpmp�'
State of � pr� ���'�A- . hereby certify that U- � �orT hJ4L4u<:C
Personally accepted before nle this day and under oath acknowledged that the above form was
executed bymwner(s).
Witness n1y hand and notarial seal, this / day of /� ~ �~ ���r20
J-
K8y Commission expires / - '-7
.
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WALLACE