NCC250279_FRO Submitted_20250131

FINANCIAL RESPONSIBILITY/OWNERSHIP STATEMENT
As per 15A NCAC 04B .0118—The draft Erosion and Sediment Control Plans will not be approved until
an authorized statement of financial responsibility and ownership is submitted.
As per GS 113A-54.1(a) - If the applicant is not the owner of the land to be disturbed,the owner's written
consent for the applicant to submit a draft Erosion and Sediment Control Plan and to conduct the
anticipated land-disturbing activity must be submitted with this document.
PART A.
1. Project Name: High Point North Industrial Center- Roadway Extension and Improvements - Phase 2
2. Physical Address/Location:
Street Address: 8545 Adkins Rd City: Colfax State:_ NC Zip: 27235
3. Latitude: 36.0805 Longitude: -80.0105
4. Approximate date land-disturbing activity will commence: October 2023
5. Purpose of development(residential, commercial, industrial, etc.)
Public roadway extension
6. Approximate acreage of land to be disturbed or uncovered: 10.40
7. Landowner(s) of Record (use blank page to list additional owners):
350 South Land Holding, LLC PNK NC 1, LLC
Name Name
2022 Shimer Rd 1100 Peach Tree St, Suite 800
Current Mailing Address Current Mailing Address
Jamestown, NC 27282 Atlanta, GA 30309
City, State, Zip City, State, Zip
888-336-3366
Telephone Number Telephone Number
8. Indicate book and page where deed or instrument is filed (use blank page to list additional deeds
or instruments). Provide copies of Deeds with this submittal.
Book See Attached Page
Book Page
FinResFm. Page# 1

PART B.
1. Person(s) or firm(s) who are financially responsible for this land-disturbing activity:
350 South Land Holding. LLC
Name Name
4716 Hilltop Road
Current Mailing Address Current Mailing Address
Greensboro, NC 27407
City, State, Zip City, State, Zip
888-336-3366
Telephone Number Telephone Number
2. Registered agent, if any, for the person or firm who is financially responsible:
Signature Mailing Address
Printed Name Telephone Number
3. 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 if not an individual, by an officer, director, partner or attorney-in-fact, or registered
agent with 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.
G'r ,N J]z moun -e.—
Type or Print Name Title of Adhority
Signature Date
I, (DI IV feD ' I'1pthgaff , a Notary Public of the County of FOrm14y , State of North
Carolina, do hereby certify that �� �-1. �'izlrF�A► �r: , appeared personally before me
this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial ial seal, this 2 day of ,I T , 20 2-3 .
,., P gRES ',,,y�, Notary Public
100
Ov• OS-Zs • 202 i
:� �O���s; My commission expires:
i NOTARPUBOG
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CO)• a FinResFm. Page # 2