NCC221846_FRO Submitted_20220513

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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 NIA in the blank.)
Part A. Lake Brandt Neighborhood Village Road Widening
1. Project Nameg--±± g g
2. Location of land -disturbing activity: CountyGuilford City or Township Greensboro
Highway/Street Lake Brandt Rd, Trosper Rd Latitude 36. 1 63067 Longitude-79.832475
1 Approximate date land --disturbing activity will commence:5/15/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Road Widening
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):' 19
6. Amount of fee enclosed: $1 7400 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 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 $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No Enclosedx
$. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameKen Miller E-mail Address [e-mail]
Telephone[phone] cell 4336-314-1616 Fax4
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sun Capital, Inc. 336-314-1616
Name Telephone Fax Number
300 N. Greene St., Suite 1750 (same)
Current Mailing Address Current Street Address
Greensboro NC 27401
City State Zip City State Zip
10. Deed Book No. Bee next page Page No. 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 attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be fisted as the financially responsible party.
Sun Capital, Inc. [e-mail]
Name E-mail Address
300 N. Greene St., Suite 1750 (same)
Current Mailing Address Current Street Address
Greensboro NC 27401
City State Zip City State Zip
Telephone [phone] Fax Number

10. Deed County: Guilford Book: 7719 Page: 1838
Book:7726 Page:2869
Book:7818 Page:1073
Book:7836 Page:1568
Book:7871 Page:2364

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Hugh Creed Associates, inc., PA [e-mail]
Engineering Firm or other consultant E-mail Address
Dalton Ward 336-275-9826
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.
IV—eflne4- 3). Mi I ter )"ires(der t, 5'7-'wC,
Type or prin me Title or Authority
Signat"A ©ate
---------__ _ -________________-------------------------------------------------
I, 1-4'm,6 Lo mores -,a Notary Public of the County of &) ! 1 j'4 .
State of North Carolina, hereby certify that µiUr{ 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 _2-(O day of Af r t { 20 d-Y
tLY L , ��
s r � TA R _ " Notary
My Comm. Exp. My commission expires
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