NCC230274_FRO Submitted_20230131

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. Exchange at Indian Trail
1. Project Name g
2. Location of land -disturbing activity: County Union City or Township Indian Trail
Highway/Street Plyler Road Latitude 35dO4'26"N Longitude 8Od39'3911W
3. Approximate date land -disturbing activity will commence: May 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 22.17
6. Amount of fee enclosed: $ 1,495.00 The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Nicholas Parker E-mail Address nrparker�amicuseng.com
Telephone [phone] cell # 704-902-5771 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Dean Harrell/Darren Sutton 704-870-4613
Name Telephone Fax Number
5615 Potter Road
Current Mailing Address Current Street Address
Matthews, NC 28104
City State Zip City
10. Deed Book No. 6497 Page No. 480
State
Zip
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 listed as the financially responsible party.
Exchange Indian Trail Apartments, LLC [e-mail]
Name E-mail Address
3300 Northeast Expressway, Bldg.6 3300 Northeast Expressway, Bldg. 6
Current Mailing Address
Atlanta, GA 30341
City
Current Street Address
3300 Northeast Expressway, Bldg. 6
State Zip City
Telephone [phone] Fax Number n/a
State
E

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:
National Registered Agents, Inc.
Name E-mail Address
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh, NC 27615
City
Telephone
Current Street Address
State Zip City
Fax Number
State Zip
(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
Telephone
E-mail Address
Current Street Address
State Zip 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.
Thomas Gunter
Type or print name
Signature
COO
Title or Authority
3/3/20
Date
Marzena Demko , a Notary Public of the County of GWinnett
State of North Carolina, hereby certify that Thomas Gunter appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
W30th March 20
Witness my hand and notarial seal, this day of 20_
``,ar Z ens
Notary `4F .' N
Seal �• ota� '; o
My commission expires
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