NCC243295_FRO Submitted_20241028

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 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.
Trail Ridge SID Phase 2b
1. Project Name
Forsythe Kernersville
2. Location of land-disturbing activity: County City or Township
SR2037
Highway/Street County Line Road Latitude(declmaldegrees) 36.1343 Longitude(declmaldegrees) 80.0403
August 2024
3. Approximate date land-disturbing activity will commence:
Residential
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):_11.13
1200.00
6. Amount of fee enclosed: $ . 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 0 Enclosed ® No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Joe Hornlein [e-mail]
Name E-mail address
919-374-3473 919-961-2505
Phone: Office# Mobile#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
H&H Construction of Fayetteville 919-374-3473
Name Phone: Office# Mobile#
7200 Falls of the Neuse Road, Ste. 202
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
79 16
10. Deed Book No. Page No. Provide a copy of the most current deed.

Part B. N/A
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(les):
DHF, LLC
Company Name E-mail Address
14701 Philips Hwy Ste 300
Current Mailing Address Current Street Address
Jacksonvile,FL32256
City State Zip City State Zip
Phone:Office it 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:
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)
(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:
k Porr KJ-44 in , In• 41 oyrn :Vt dv ftfr,d4.-�ho
Name of Registered Agent �^ it ddress Co -e
W 4, '` tia q t�
Current MailingMailing Add kr-ssloo 1 ' �� d Current Street Address
tt
� t6t ki °7--414 fC
City Li State Zip City State Zip
Phone: Office# ( (A) *-3413 Mobile it NJ f I�
IV(
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. rr
d0 k /vt( .R.�i Vl „r of. ±i o
T/ZoPrint
ame Title or Authority
ignature Date
I R 'kJJ "- 5 & J(4 , a Notary Public of the County of (./JIe1/4-1
State of North Carolina, hereby certify that oE h orn I et n 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 )`1-1 day of 0 , 2022.
ONA6/12rjk --JA-04/11(2--
Notary
Seal IrZ
My commission expires
„„..illllp.„,
.�`��ooh Steil
`��`�Q, ,pT ARy,,,~
My Comm.Exp.
08-29-2028
GL'•., .o G U
,4 e C0ur\�sos`‘`
�•gi/f1111111oo