NCC242072_FRO Submitted_20240711

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 NCGO1 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 Trollingwood Townes Phase 2
!f this project involves}A.r:eroan Rescue Plat �which
;gctt(ARPA)}p funds,
,Rlist
lthe
lProject
Name
yor Project
_ N..im Der f vl 1R ...a `�RP-0 l)w under Ye�hi�.. you were approved 7o! fundingthrough the
Division of Water infrastructure(LAM).
2. Location of land-disturbing activity: County Ala mance City or Township Town of Haw River
Highway/Street Troilingwood Road Latitude decin;al de reel 3fi.0506& g 79.21066
g } Lon Itude decimal degrees)
3. Approximate date land-disturbing activity will commence: May,2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11.87
6. Amount of fee enclosed: $ 1,200.00 . 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 NCOEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed %i No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Ford _ E-mail [e-mail]
Phone: Office# [phone]
Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Trollingwood investments, LLC [phone] 336-707-0480
Name • Phone: Office# Mobile#
7 Corporate Center Court,Suite B 7 Corporate Center Court,Suite B
Current Mailing Address Current Street Address
Greensboro NC 27408 Greensboro NC
27408
City State Zip City State Zip
10. Deed Book No. 4549 Page No._804 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the hand-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).
Trollingwood Investments,LLC [e-mail]
Company Name E-mail Address
7 Corporate Center Court,Suite B 7 Corporate Center Court,Suite B
Current Mailing Address v Current Street Address
Greensboro NC 27408 Greensboro NC 27408
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
-Not : if the Fzinaneially Repo sgb e Party i not the ownerof tite 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:
Ford Development and Consulting,Inc. [e-mail]
Name of Registered Agent E-mai: Address
P.O.Boa 474 _ • 7 Corporate Center Court,Suite B
Current Mailing Address Current Street Address
Summerfield NC 27358 Greensboro NC 27408
City - State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
Brian Ford
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.
Brian Ford Authorized Signatory
Type or print name Title or Authority
Signature Date
I, lit IDClllN1 D C fV 6
, a Notary Public of the County of Livi fc5,4
State of North Carolina, hereby certify that br'r 6''61 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 1- day of i`eb(Ct . , 20
H. DAWN NICHOLS Notary
� '• n: o ::1:8
ary Public, North C
Guilford Cunty 1 , Q, gyp,/
*� •f 4 My commission expires �( �3/ Z 2�`�
"` �' October 02,2024