NCC223759_FRO Submitted_20221104

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Chandler Concrete
2. Location of land -disturbing activity: County Davie City or Township Farmington
Farminglan RBI Commercial Way 35.957944-80,536453
Highway/Street LatltUde(decimal degrees) LOngltude(decimal degrees]
3. Approximate date land -disturbing activity will commence: October 14, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Concrete Plant
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 3.85
6. Amount of fee enclosed: $ $400 . 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).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJamie Nelms E-mail Address [e-mail]
Phone: Office # 336-226-1181 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners).
Kime Street Properties, LLC 336-516-2666
Name Phone: Office # Mobile #
1006 South Church Street
Current Mailing Address
Burlington, NC 27215
City
State
10. Deed Book No. 1213
Current Street Address
Zip City
Page No. 01 59
State
Zip
Provide a copy of the most current deed.

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).
Kime Street Properties, LLC [e-mail]
Company Name E-mail Address
1006 South Church Street
Current Mailing Address Current Street Address
Burlington, NC 27215
City State Zip City State Zip
Phone: Office # 336-516-2666 Mobile #
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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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
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.
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Type or print ZZ&
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Signature
MFAI,E fZ
Title or Authority
Dat
I, _A , a Notary Public of the County ofzi4���
,
State of North Carolina, hereby certify that A) Jbie r- t l3. C ha e L,/ ►F_appeared personally
before me this day and being duly sworn ackn wledged that the above form was executed by him/her.
Witness my hand and notarial seal, this _�G 4y of &. , 20 Z
r� Phyllis A Gorman
NOTARY PUBLIC
Alamance County, NC
ota ry /1'
y commission expire 2,6

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Farmstead Lane Limited Partnership, PLLP
Name Phone: Office # Mobile #
120 Farmstead Lane
Current Mailing Address Current Street Address
Mocksville, NC 27028
City r� State Zip City State Zip
Deed Book No. 0o 84 Page No. 0980 Provide a copy of the most current deed.
Landowner 3 of Record
George Haire and Lena C. Haire
Name Phone: Office # Mobile #
120 Farmstead Lane
Current Mailing Address Current Street Address
Mocksville, NC 27028
City State Zip City State Zip
Deed Book No. 0561 Page No. 0567 Provide a copy of the most current deed.
Landowner 4 of Record:
BRJ Properties, LLC
Name Phone: Office # Mobile #
259 North Carolina Circle
Current Mailing Address Current Street Address
Mocksville, NC 27028
City State Zip City State Zip
Deed Book No. 0867 Page No. 0262 Provide a copy of the most current deed
Landowner 5 of Record
Name
Current Mailing Address
City
Deed Book No.
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
State Zip
State Zip
State Zip