NCC223110_FRO Submitted_20220907

FINANCIAL RESPONSIBILITY/OWNERSHIP STATEMENT
As per 15A NCAC 04B .0118 — The draft Erosion and Sediment Control Plans will not be approved until
an authorized statement of financial responsibility and ownership is submitted.
As per GS I I3A-54.1(a) - If the applicant is not the owner of the land to be disturbed, the owner's written
consent for the applicant to submit a draft Erosion and Sediment Control Plan and to conduct the
anticipated land -disturbing activity must be submitted with this document.
PART A.
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3.
4.
5.
6.
7.
Project Name: High Point North Industrial Center -Roadway Extension and Improvements
Physical Address/Location:
Street Address: 2419 Sandy Ridge Rd City: High Point state: NC zip: 27235
Latitude: 36.0778
Longitude:-79.9936
Approximate date land -disturbing activity will commence: July 2022
Purpose of development (residential, commercial, industrial, etc.)
Public roadway extension
Approximate acreage of land to be disturbed or uncovered:
13.60
Landowner(s) of Record (use blank page to list additional owners):
350 South Land Holdings, LLC
Name
4716 Hilltop Road
Current Mailing Address
Greensboro, NC 27407
City, State, Zip
888-336-3366
Telephone Number
Name
Current Mailing Address
City, State, Zip
Telephone Number
8. Indicate book and page where deed or instrument is filed (use blank page to list additional deeds
or instruments). Provide copies of Deeds with this submittal.
r,
Book See Attached
Page,,;'
Page,
F igOsErp. Page #

PART B,
Person(s) or firm(s) who are financially responsible for this land -disturbing activity:
350 South Land Holdings, LLC
Name
4716 HUItop Road
Current Mailing Address
Greensboro, NC 2740,7,,..,._..._
City, State, Zip
888-336-3366
Telephone Number
Name
Current Mailing Address
City, State, Zip
Telephone Number
2. Registered agent, if any, for the person or firm who is financially responsible:
S ignature
Printed Name
Mailing Address
Telephone Number
3, 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 if not an individual, by an officer, director, partner or attorney -in -fact, or registered
agent with 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.
V�CWO . 6- l (_1 "11_ 0 �) f I Manager
Type or Print Name Title of Authority
I'D J-34
C
Signature Date
1, C )L ti d A t�1 1a , a Notary Public of the County of �� °1 , State of North
Carolina, do hereby certify that Mga 11YS4Ar) .�) f , appeared personally before me
this day and being duly sworn acknowledged that the above
Witness my hand and notarial seal, this day of
sslon ti
Q ' aR '[PRY s
t AusL ILI z' s
.n •:
Notary Public
My commission
s executed by him,
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FinResFm. Page # 2