NCC190579_ESC Approval Submitted_20190611

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person ryiay initiate any land4sturbing 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 Environment and Natural Resources. (Please type or print and, H
the question is not applicable or the e-mail and/or fax information unavailable,place N/A in the blank.)
Part A.
1. Project Name RoUl Pines Subdivision,Phase 3
2. Location of land-disturbipg activity, County Randolph City or Township Archdale
Highway/Street Archdale Road Latftudq._35.860 Longitude-A7 .929
S. Approximate date land-disturbing activity will commence: June.2019
4. Purpose of development(residential,commercial,industrial,Institutional,etc.):. -Residential
5. Total acreage disturbed or uncovered(including off-site,borrow and waste areas):
13.2 AC/1?,RAC Basin
6. Amount of fee enoloseO;Included_lnTRC fees.
7. Has an erosion and sediment control plan been filed? Yes�—No Enclosed-,X—
B. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name $�—Mtt Wallace E-mail Address swallace0nokeystone.ggm
Telephone [phone] Coll# Fax 9
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, or It not an individual, by an officer,director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide.,
corrected Information should there be any change in the information provided herein.
Scoff Wallace reside..
Type or print name Title or Authority
resi
Signature Date
'Q mp 1,,,e 04 11 a-e� a Notary Public of the County of
State of North Carolina, hereby certify that W . 54,o-rT 04LIACC appeared
personally before me this day and being duly sworn acknowledged that the above form Was
executed by him.
Witness my hand and notarial seal,this--Z—day of 20-1—
L TEMPLE WALLACt
NOTARY PUBLIC
CO
GUILFORD=COUNW, NC
Conintiollon*I)PIres OL'l- Notary
My commission expires—