NCC230353_FRO Submitted_20230208

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 be 'ore 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 addr( ss or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Williams Grove- Phase 4 (Deed Book and Page number: 3143: 483-4, H )
2. Location of land -disturbing activity: County Nash City or Township Bailey
Highway/Street Stoney Hill Church Rd Latltude(decimai degrees)35.808055 Longltude(decimal degr( as)-78.066965
3. Approximate date land -disturbing activity will commence: 2/13/23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residentie 1
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 80.7 acr ;s
6. Amount of fee enclosed: $payment previously sent . The application fee of $100.00 per a :re (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 2 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing a .tivity:
Name CECIL WILLIAMS E-mail Address [e-mail] m
Phone: Office # 252-205-1151
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
C.T. WILLIAMS CORPORATION 252-205-1151
Name
3303 SUNSET AVE, STE H
Current Mailing Address
ROCKY MOUNT NC
City State
10. Deed Book No. 3143
Phone: Office # Mobile #
3303 SUNSET AVE, STE H
Current Street Address
27804 ROCKY MOUNT NC 7804
Zip City State Zip
Page No. 483-491 Provide a copy of the most ci irrent deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a coml rehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the andowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
C.T. WILLIAMS CORPORATION
Company Name
3303 SUNSET AVE, STE H
Current Mailing Address
ROCKY MOUNT NC 27804
City
State Zip
Phone: Office # 252-205-1151
[e-mail]
E-mail Address
3303 SUNSET AVE, STE H
Current Street Address
ROCKY MOUNT NC 27804
City State Zip
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include vith this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and s )dimentation
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 Secretai y of State
business registry, give name and street address of the Registered Agent. -
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office # N/A Mobile # N/A
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 st eet address
of the designated North Carolina agent who is registered on the NC Secretary of State busin( ss registry:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Phone: Office #
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Mobile #
1-d111c ui muiviauai io 1—ontact (it Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, giv ; name under
which the company is Doing Business As. If the Financially Responsible Party is an indivi ival, General
Partnership, or other company not registered and doing business under an assumed name, a ttach 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 w as provided
by me under oath. (This form must be signed by the Financially Responsible Person if an ndividual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registere t agent with
the authority to execute instruments for the Financially Responsible Party). I agre( to provide
corrected information should there be any change in the information provided herein.
CECIL WILLIAMS
Type or print name
Signature
MANAGER
Title or Authority
Date
'ihcX ( C a Notary Public of the County of l��
State of North Carolina, hereby certify that Cu-0 WN(Cao'A appear& i personally
before me this day and being duly sworn acknowledged that the above form was executec by him/her.
Witness my hand and notarial seal, this day of V 20--,73
W-0 v
�Otary
My commission expires
NOTARY PUBLIC
WILSON COUNTY
STATE OF NORTH CAROLINA