NCC223352_FRO Submitted_20220927

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Beacon Point
2. Location of land -disturbing activity: County Wake City or Township Raleigh
Highway/Street 1425 Promise Beacon Latitude(decimai degrees) 35.7590 Longltude(decimal degrees) -78.6159
3. Approximate date land -disturbing activity will commence: 9/26/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.38
6. Amount of fee enclosed: $ 400 . The application fee of $100.00 per acre (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 V Enclosed ❑ No ❑
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert Young E-mail Address ![e-mail]
Phone: Office # 919-683-1701 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Young Men's Christian Association of the Triangle Area, Inc. 919-345-5596
Name Phone: Office # Mobile #
801 Corporate Center Drive, Suite 200 Same as mailing
Current Mailing Address Current Street Address
Raleigh
City
NC 27607
State Zip
City
State
sm
10. Deed Book No.016221 Page No. 01206 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).
Romeo Guest Associates, LLC [e-mail]
Company Name
P.O. Box 890
E-mail Address
1715 Camden Avenue
Current Mailing Address Current Street Address
Durham NC 27702 Durham NC 27704
City State
Phone: Office # 919-683-1701
Zip City State
Mobile # [phone]
Zip
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:
James B. Robbins, II [e-mail]
Name of Registered Agent
P.O. Box 890
Current Mailing Address
Durham NC
City State
Phone: Office # 919-683-1701
E-mail Address
1715 Camden Avenue
Current Street Address
702 Durham NC 27704
Zip City State Zip
Mobile # [phone]
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
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Mike Monce
Type or print name
�v4z,-
Signature
Senior Project Manager
Title or Authority
9/23/2022
Date
I, Mir-hGlle-J- MrTo ,l , a Notary Public of the County of br'cn'jc
State of North Carolina, hereby certify that M 1(Ct Monk appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this a3 day of SCE mbGt 20 2-)-
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1007. �•,
•'- Notary
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t,CT�Y �'`• - My commission expires
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Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
SHVF Beacon Point, LLC [e-mail]
Company 2 Name E-mail Address
301 W. Main St. Same as mailing
Current Mailing Address Current Street Address
Durham NC 27701
City State Zip City State Zip
Phone: Office # 919-956-4462 Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
E-mail Address
State Zip
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #

FOR YOUTH DEVELOPMENT
FOR HEALTHY LIVING
FOR SOCIAL RESPONSIBILITY
September 22, 2022
To whom it may concern,
I consent for Romeo Guest Associates, LLC, on behalf of SHVF Beacon Point, LLC, to submit a draft
erosion and sedimentation control plan and to conduct the anticipated land disturbing activity on
property owned by the YMCA of the Triangle at Beacon Point, 1425 Rock Quarry Rd., Raleigh NC 27610.
Sincerely,
`t
Brian Keel
YMCA OF THE TRIANGLE
Association Resource Center, 801 Corporate Center Drive, Suite 200, Raleigh, NC 27607
P 919-719-9622 • www.YMCATriangle.org
OUR MISSION: To put Christian principles into practice through programs that build healthy spirit, mind and body for all,