NCC220971_FRO Submitted_20220308

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. LibertyPoint Industrial Park - Lots 2 & 3
1. Project Name
2
3
4
Location of land -disturbing activity: County Cumberland City or Township Hope Mills
Highway/Street Corporation Dr/SR2333 Latitude 34.9415 _ Longitude-78.9010
Approximate date land -disturbing activity will commence: January 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
18.74
6. Amount of fee enclosed: $ 1,900 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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:
Nance Alex Hale E-mail Address [e-mail]
Telephone [phone]
Cell # 336-707-1797 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners).
Williams Liberty Point, LLC
Name
2709 Thorngrove Ct, Suite 1
Current Mailing Address
Fayetteville, NC 28303
Telephone Fax Number
2709 Thorngrove Ct, Suite 1
Current Street Address
Fayetteville, NC 28303
City State Zip City State Zip
10. Deed Book No. 10858, 10858 page No. 01 19, 0123 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.
Liberty Point Two, LLC [e-mail]
Name
5603 New Garden Rd
Current Mailing Address
Greensboro, NC 27410
City
E-mail Address
5603 New Garden Rd
Current Street Address
Greensboro, NC 27410
State Zip City
Telephone [phone] Fax Number
State
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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
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.
Type or print name Titl or Authority
�Sf 717-
Signature Date
I, C a r al y n D r o,.i\ a Notary Public of the County of
State of North Carolina, hereby certify that Lo r , a u Y' appeared
personally before me this day and being duly sworn acknowledge6 that the above form was
executed by him.
Witness my hand and notarial seal, this .
Seal
OFFICIAL SEAL
Nr:' ikj Public - North Carolina
��3-C�KES COUNTY
CA iOL-YN H. MORAN
fkr' Coa -mission Ex0res
day of, _7S4htKCA ,24 � '�—
Notary
My commission expires
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