NCC222274_FRO Submitted_20220622

a
RECEIVED
JUN :2 8 2021
FIN NCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT O MLR
Regional Office
No person may initiate any land -disturbing activity on one or more acres as covered y the Act befor 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 NIA in the blank.)
Part A. MCLEAN LANDING SUBDIVISION
1. Project Name
2. Location of land -disturbing activity: County MOORE City or Township LITTLE RIVER
Highway/Street SR 20191MARKS ROAD Latitude 35° 12'37.79"N Longitude 790 9'20.03"W
Au 152021 &
3. Approximate date land -disturbing activity will commence: g,
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.2
6. Amount of fee enclosed: $ 845 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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:
Name Scott Clark E-mail Address [e-mail]
Telephone [phone] Cell # 919-244-1004 Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BC Prime, Inc
919-612-5399 NA
Name
Telephone Fax Number
4312 Samantha Drive
4312 Samantha Drive
Current Mailing Address
Current Street Address
Raleigh NC
27613 Raleigh NC 27613
City State
Zip City State Zip
10, Deed Book No. 5521
Page No. 4H-54 Provide a copy of the most current deed.
Part B.
1. Company(les) 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 orfrrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
BC Prime, Inc
[e-mail]
Name
E-mail Address
T. Brandon Brown
4312 Samantha Drive
Current Mailing Address
Current Street Address
Raleigh NC
27613 Raleigh NC 27613
City State
Zip City State Zip
Telephone [phone]
Fax Number NA

2. (a) If the Financially Responsible Parry 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 State Zip
Telephone
Fax Number
(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.,
T. Brandon Brown
[e-mail]
Name of Registered Agent
E-mail Address
4312 Samantha Drive
4312 Samantha Drive
Current Mailing Address
Current Street Address
Raleigh NC 27613
Raleigh NC 27613
City State Zip
City State Zip
Telephone [phone]
Fax Number NA
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.
T. Brandon Brown
President
Type or print name
Title or Authority
Signature
Date
I, I ` . l - , a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of f— , 20�
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