NCC216227_FRO Submitted_20211109

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. Volcano Restaurant
1. Project Nani
2. Location of land -disturbing activity: County Pasguotank City or Township Elizabeth City
Highway/Street Commercial Blvd. Latitude 36.29420 Longitude-76.30000
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): 2.6
6. Amount of fee enclosed: $ 195.00 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Morris E-mail Address [e-mail]
Telephone [phone] Cell # 252-621-5014 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners).
Shuang Long Realty, LLC 646-283-7680
Name Telephone Fax Number
121 Pineview Drive 121 Pineview Drive
Current Mailing Address Current Street Address
Elizabeth City NC 27909 Elizabeth City NC 27909
City State Zip City State Zip
10. Deed Book No._1358 Page No. 715 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.
Shuang Long Realty, LLC [e-mail]
Name E-mail Address
121 Pineview Drive
Current Mailing Address
Elizabeth City NC 27909
City State Zip
Telephone [phone]
121 Pineview Drive
Current Street Address
Elizabeth City NC 27909
City State Zip
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:
N/A
Name
N/A
Current Mailing Address
N/A
City State
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip City
Fax Number N/A
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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip city
Fax Number N/A
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.
Gui Xiang Huang
Manager
Type or print name Title or Authority
Signature Date
a Notary Public of the County of ayk
State of North Carolina, hereby certify that00 appeared
personally before me this day and being duly sworn a owledgedthat the above form was
executed by him.
Witnep„finy il�ppd and notarial seal
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