NCC215341_FRO Submitted_20210928

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 NIA in the blank.)
Part A. Carolina Creations Landscape, Inc. Light Industrial Subdivision
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Shallotte
Highway/Street Forest St. Ext. NW Latitude33•999561 G Longitude-78.376689 0
3. Approximate date land -disturbing activity will commence: November 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.088
6. Amount of fee enclosed: $ 1,105 . 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 Art Miller E-mail Address [e-mail]
Telephone [phone] cell # 910-443-5500 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Carolina Creations Landscape, Inc 910-755-6411
Name Telephone
PO Box 2327 4802 Bailey Street
Current Mailing Address Current Street Address
Shallotte NC 28459 Shallotte NC
City State
10. Deed Book No. Q4665
Zip City
Page No. 0623
State
Fax Number
28470
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.
Carolina Creations Landscape, Inc [e-mail]
Name E-mail Address
PO Box 2327 4802 Bailey Street
Current Mailing Address
Shallotte NC
City State
Telephone [phone]
Current Street Address
28459 Shallotte NC
Zip City State
Fax Number
28470
Zip

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:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
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). 1 agree to provide
corrected information should there be any change in the information provided herein.
Art Miller
Type or print name
Sig a re
President
Title or Authority
Ofs��$f2
Date
I, �2 % ) a Notary Public of the County of
State of North Carolina, hereby certify that P�-` or ' Ir-->- appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 1 day of u�a� , 20
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COMMISSIOM My commission expires
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