NCC232032_FRO Submitted_20230703

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 Environment and Natural Resources. (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: Kyndall Run Subdivision
2. Location of land-disturbing activity: County: Davidson City or Township: Lexington
Highway/Street: Leonard RoadjSR1459) Latitude: 35°52'44.84"NLongitude: 80°15'28.37"W
3. Approximate date land-disturbing activity will commence: As Soon As Possible
4. Purpose of development(residential, commercial, industrial, institutional, etc.): single family residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 30.10 acres
6. Amount of fee enclosed: $1.950. 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 Barry Siegal E-mail Address: [e-mail]
Telephone [phone] Cell#336-292-9010 Fax
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Barry Siegal
Name Telephone Fax Number
PO Box 16168 High Point, NC 27261 PO Box 16168 High Point, NC 27261
Current Mailing Address Current Street Address
High Point NC 27261 High Point NC 27261
City State Zip City State Zip
10. Deed Book No. 2390 Page No. 1235-1238 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Leonard Road Partners, LLC bscholdingaaol.com
Name E-mail Address
PO Box 16168 4425 Monument Trace, Suite 101
Current Mailing Address Current Street Address
High Point NC 27261 Greensboro NC 27409
City State Zip City State Zip
336-292-9010
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Barry Siegal bscholding(a?_aol.com
Name of Registered Agent E-mail Address
PO Box 16168 4425 Monument Trace, St. 107
Current Mailing Address Current Street Address
High Point N C 27261 Greensboro NC 27409
City State Zip City State Zip
Telephone [phone] Fax Number
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.
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Type or print nand Title or Authority
Signature Date
I, J4i N4-j Tam iftlkk , a Notary Public of the County of vttaise.a.....
State of North Carolina, hereby certify that . appeared
personally before me this day and being duly acknovdged that the above form was
executed by him.
Witness my 011 VA-�x�l seal, this 24� day of , 20 za
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