NCC222152_FRO Submitted_20220610

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. Garnet Place
1. Project Name
6
Location of land -disturbing activity: County Brunswick City or Township Shallotte
Highway/Street Arnold Street Latitude 33.986609 Longitude-78.384471
3. Approximate date land -disturbing activity will com
4.
5.
6.
7.
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4'78 acres
Amount of fee enclosed: $ 500 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).
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:
Name Tammy Stern E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
McFearann, LLC CO: Teresa McLamb [phone]
Name
PO Box 4640
Current Mailing Address
Calabash NC
City State
10. Deed Book No. 04021
Telephone Fax Number
Arnold Street
Current Street Address
28467 Shallotte NC 28470
Zip City
Page No..0661
State
LI p
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.
Mills Construction Company of SC, Inc. [e-mail]
Name
PO Box 6171
Current Mailing Address
Raleigh NC
City State
Telephone [phone]
27628
Zip
E-mail Address
PO Box 6171
Current Street Address
Raleigh NC
k,Iry
Fax Number
State
27628
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
uiry
Telephone
E-mail Address
Current Street Address
State Zip City
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
City
Telephone
State
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
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.
Fred Mills, Jr
Typrint name
�• 1
Signature
President
Title or Authority
_.3-9— 0z�
Date
kl6ye •Af- , a Notary Public of the County of
State of North Carolina, hereby certify that �r� c). iy.r 115 Tr - appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Cj-PL-
Witness my hand and notarial seal, this I day of 11yal'GL , 2022-
JOSEPH R WARENDA jam.
NOTARY PUBLIC
WAKE COUNTY, NC NottV
Seal r commission Exom 6*2023
My commission expires �a 3