NCC221839_FRO Submitted_20220513

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 NameHorne2-Tru Dual Brand Hotel
2. Location of land -disturbing activity: County Robeson —City or Township Lumberton
Highway/Street,jackson Ct. Latitude(decimal degrees) 34.66719 Long itude(decirrial degrees) -79.0054
3. Approximate date land -disturbing activity will commence: J u n e 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):3.0
6. Amount of fee enclosed: $300.00 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.1 0-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed Ex No F1
8. , Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameArnit Patel E-mail Address [e-mail]
Phone: Office # 91 9-468-9190 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LUM-LOT 3, LLC 919-468-9190 919-225-5197
Name
4131 Parklake Ave #360
Current Mailing Address
Raleigh NC 27612
Phone: Office # Mobile #
4131 Parklake Ave #360
Current Street Address
Raleigh NC 27612
City State Zip City
10. Deed Book No.2282 Page No.273-277
State
0
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(ios).
LUM-LOT 3, LLC
Company Name
4131 Parklake Ave #360
Current Mailing Address
Raleigh NC 27612
City State Zip
Phone: Office # 91 9-468-9190
amit(FDwinwoodhospitality.com
E-mail Address
4131 Parklake Ave #360
Current Street Address
Raleigh NC 27612
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:
Name of Registered Agent
4131 Parklake Ave #360
[e-mail]
E-mail Address
4131 Parklake Ave #360
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Phone: Office #919-468-9190,
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 on individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
ofthe Certificate ofAssumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledgeond belief and was provided
bvnneunder oath. (This form must be signedbvtheFinoncio|k/ReaponSib|ePersonif8nindkjdVaKs)
or his 8ttOrnoy-in-fact, or if not on individUG|, by an offioer, director, partnor, or registered agent with
the authority to execute instruments for the Financially Responsible Party). | G0n3e to provide
corrected information should there be any change in the information provided herein.
re
Registered Agent/Managing KAeM0hp[
Title or Authority
A �/' -'� 26;�e.2
Date
[allotary Public 0fthe County of
GtateofNorth Carolina, hereby certify that
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness rnyhand and notarial seal, this ayof 20 22-
Notary
i /
My commissionexpires