NCC222368_FRO Submitted_20220708

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 Environment and Natural Resources. (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.
Project Name: Evolve Holly Rid e RV
2. Location of land -disturbing activity: County: Onslow City or Township: Holly Ridge
Highway/Street E Ocean Road- Latitude: 34' 29' 04" N Longitude: 77' 33' 17W
3. Approximate date land -disturbing activity will commence: February 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 17.18_
6. Amount of fee enclosed: $ 1170 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mike Winstead E-mail Address: mike a-evo lvecos. com
Telephone: [phone] Fax #: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Evolve RV Holly Ride LLC [phone]
Name Telephone
Fax Number
2918 A Martinsville Road Same as Mailing Address
Current Mailing Address Current Street Address
Greensboro NC 27408
City State Zip City State Zip
10. Deed Book No. 5216 Page No. 876-879 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Evolve RV Holly Ride LLC 910 239-9120
Name Telephone Fax Number
2918-A Martinsville Road Same as Mailing Address
Current Mailing Address Current Street Address
Greensboro NC 27408
City State Zip City 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 E-mail Address
Current Mailing 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:
Name of Manager
Current Mailing Address
City State Zip
Telephone:
E-mail Address
Current Street Address
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 informatiWshoulq,#iere be My changq4h the information provided herein.
Mike Wins d t
Type or print rMeg //j.
Signature
Title or Authority
Date
1 /2-?l -z-
I, &51(e AAC N 0 0 Y_, a Notary Public of the County of P aid -over
State of North Carolina, hereby certify that 91k 1440' appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 110
Witness;m'y'hand,.a'f o..notarial seal,
this day of �' �� 20,,_
vL �
Not
My commission expires