NCC222142_FRO Submitted_20220623

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1
2
3
Project Name BEAVER CREEK SUBDIVISION = PHASES 5&6
Location of land -disturbing activity: County NASH City or Township TOWN OF MIDDLESEX
Clause Lewis Rd N35.7731389 W78.1788056
Highway/Street LatltUde(decimaldegrees) LOngltUde(decimaldegrees)
Approximate date land -disturbing activity will commence: 06/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26.8
6. Amount of fee enclosed 2,700+2,000 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name MATT HANNA E-mail Address [e-mail]
Phone: Office # 301-979-2223 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Little Bear Creek Properties LLC 301-979-2223 301-979-2223
Name Phone: Office # Mobile #
755 Ranch Road 755 Ranch Road
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
10. Deed Book No. 3146 Page No. 632 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Little Bear Creek Properties B, LLC
Company Name
755 Ranch Road
Current Mailing Address
Clayton NC 27520
City State Zip
Phone: Office # [phone]
[e-mail]
E-mail Address
755 Ranch Road
Current Street Address
Clayton NC 27520
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
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 Secretary of State
business registry, give name and street address of the Registered Agent:
David Geiger [e-mail]
Name of Registered Agent E-mail Address
755 Ranch Road 755 Ranch Road
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
Phone: Office # [phone] Mobile # [phone]
David Geiger
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 street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
3Tier, PLLC
Engineering firm or other consultant
[e-mail]
E-mail Address
Ruben Sidranski [phone] (702) 769-569
Individual contact person (type or print) Phone: Office # Mobile #
The above information is true and correct to the best of my knowledge and belief an vid d
by me under oath. (This form must be signed by the Financially Responsible Pers w i n 1vidual(
or his attomey-in-fact, or if not an individual, by an officer, director, partner, or regis ed a ent
the authority to execute instruments for the Financially Responsible Party). 11gree ovide
corrected information should there be any change in the information p dyerein.
David Geiger Owner _ N
ype or pr" e Title or
i �:
Signature
1, Publicunty of �C>Ih.(�.D
State of North Carolina, hereby , �' e" appeared personally
before me this day and bein r) gckOlwledged that the above form was executed by him/her.
Witness my hand an al eal, t ' day of ri , 20-1
P
SRy•
CO
Notary
My commission expires

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Name
Phone: Office # Mobile #
755 Ranch Road
755 Ranch Road
Current Mailing Address
Current Street Address
Clayton
NC
27520
Clayton NC 27520
City
State
Zip
City State Zip
3194
1 7-1 9
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City
State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City
State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City
State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.