NCC216981_FRO Submitted_20211216

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 and/or
fax information unavailable, place N/A in the blank.)
Part A. 1. Project NameJones Keystone Ph. 2
2. Location of land -disturbing activity: County Randol ph City or TownshipTri n ity
Highway/Street Flake Briles Rd LatitLide35.737295 Longitude-80.016551
3. Approximate date land -disturbing activity will commence.Jan. 3 2622
4. Purpose of development (residential, commercial, industrial, institutional, etc.)- Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):2.27
6. Amount of fee enclosed: $(300) (750) The Express Permitting application fee is a dual charge.
The normal fee of 100 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJonathan Powers E-mail [e-mail]
Telephone9l 9-673-3134 cell # 919-673-3134 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Linda Hunt
n/a
Name
Telephone Fax Number
4962 Rex Rd
4962 Rex Rd
Current Mailing Address
Current Street Address
Winston Salem NC 27103
Winston Salem NC 27103
City State Zip
City State Zip
10. Deed Book No.21 1 1 Page No. 121 8 Provide a copy of the most current deed.
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 c3ttached 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.
Project
JKL, LLC
[e-mail]
Name
E-mail Address
204 Bernard Purvis Rd
204 Bernard Purvis Rd
Current Mailing Address
Current Street Address
Bennet NC 27208
Bennett NC 27208
City State Zip
City State Zip
Telephone [phone]
Fax Number n/a

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
n/a n/a
Name
E-mail Address
n/a
n/a
Current Mailing Address
Current Street Address
n/a
n/a
City State Zip
City State Zip
Telephone n/a
Fax Number n/a
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Jonathan Powers
[e-mail]
Name of Registered Agent
E-mail Address
204 Bernard Purvis Rd
204 Bernard Purvis Rd
Current Mailing Address
Current Street Address
Bennett NC 27208
Bennett NC 27208
City State Zip
City State Zip
Telephorie919-650-1158
Fax Numbern/a _
(c) In order to facilitate Express Permitting,
it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Summey Engineering Associates, PLLC
[e-mail]
Engineering Firm or other consultant
E-mail Address
Christian Vestal
336-328-0902 n/a
Individual contact person (type or print) Telephone
Fax Number
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 if 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.
Jonathan Powers
Vice President
Type orprint IlAfrke Title or Authority
/ 2 "7' 20 2)
Signature Date
I, r-ZV1_AA ��jjnrlar c a Notary Public of the County of hRr.Mn(ok
State of North Carolina, hereby certify that jn,%,a:tt.a., powers 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 - W day of Qg.ca .r%,bt! 20 V
rl'
Seal
My commission expires 9-a,,i- atJas