NCC221461_FRO Submitted_20220413

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 NIA in the blank.)
Part A.
1. Project Name Kernodle Landing Phase 4
2
3
4
5
Location of land -disturbing activity: County Alamance, City or Township Morton
Highway/Street Gerringer MITI Rd. Latitude(decimal degrees) 36.153 Long ltude(decimaldegrees) -79.479
Approximate date land -disturbing activity will commence: April, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.81 acres
6. Amount of fee enclosed S1,050.00 . The Express Permitting application fee is a dual charge_
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been fled? Yes ❑ Enclosed ;K No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Sasser
Phone: Office # [phone]
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gerringer Mill Road, LLC [phone]
Name
4425 Sasser Farms Drive
Current Mailing Address
Gibsonville, NC 27249
City State
Phone: Office #
4425 Sasser Farms Drive
Current Street Address
Gibsonville, NC 27249
Zip City
State
Mobile #
91
10. Deed Book No. 3820 Page No. 424 Provide a copy of the most current deed.
4171 74

Part B.
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(ies).
Gerringer Mill Road, LLC
Company Name
4425 Sasser Farms drive
Current Mailing Address
Gibsonville, NC 27249
City State Zip
Phone: Office # [phone]
[e-mail]
E-mail Address
4425 Sasser Farms Drive
Current Street Address
Gibsonville, NC 27249
City State Zip
Mobile # [phone]
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:
Name of Registered Agent F-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
(d) If 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:
Stoltzfus Engineering, Inc.
Engineering firm or other consultant
Aden R. Stoltzfus, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
[phone] [phone]
Phone: Office # Mobile #
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.
Kevin D. Sasser Manager
Type or pri e Title or Authority
s jw -,Mj'
Si nat a Date
I, L� �d5 (k a Notary Public of the County of 6 Ul 1-6d.
State of North Carolina, hereby certify that f 1 / 1, dl a.3se_ t' 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 day of }� , 20��
LINDSEY BECK �.
NOTARY PUBLIC
Guilford County Notary
North Carolina
Mycomml'-So EapffA r - My commission expires �l (�1(� �' i �, Joa