NCC222011_FRO Submitted_20220531

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 Name Scotia Village East Neighborhood
2. Location of land -disturbing activity: County Scotland City or Township Laurinburg
Highway/Street Elm Avenue Latitude 34.739729 Longitude-79.484511
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.6
6. Amount of fee enclosed: $ 300 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Steven Johnson E-mail Address [e-mail]
Telephone [phone] Cell # 336.558.8800 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Presybterian Homes, Inc. 336.886.6553
Name Telephone Fax Number
2109 Sandy Ridge Road 2109 Sandy Ridge Road
Current Mailing Address Current Street Address
Colfax NC 27235 Colfax NC ^/235
City State Zip City State Zip
10. Deed Book No. 10U Page No. 304 Provide a copy of thcmost current deed.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land-disturbng activity (Povide a
comprehensive list of all responsible parties on an attached sheet.) If the company or Irmis a sole
proprietorship the name of the owner or manager may be listed as the financially responsAle party.
Presbyterian Homes, Inc. [e-mail] _
Name E-mail Address
210a Sandy Ridge Road 2109 Sand 11
Curren Mailing Address Current Stre[Address�1�8_61_ YAeTrl%A
NC 27235 ColfaxColfax 235
�,.�,�City State Zip City .► tee*',3 Zip

Telephone [phone] Fax Number
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City State Zip
Telephon
E-mail Address
Current Street Address
City
Fax Number
State Zip
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.
Timothy J. Webster
President/Registered Agent
sine or print name Title or Authority
Sig na uret Dale
I, I 1 ��%%. CD a Notary Public of the County of
State of�Iuth Carolira, hereby certify that J- Y appeared
personaly tefore me tiis day and being duly sworn acknowled ed that the above form was executeu
by him.
Witness iy rand and notarial seal, this _day of _, 20 2Z
Taft M. Cox
NOTA!!Y PtlBt.IC
Ab Csi
V _ UM M MW& 4. MV
Notary
My commission expires