NCC222517_FRO Submitted_20220713

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 Name School Street Center
2. Location of land -disturbing activity: County Onslow, City or Township Swansboro
W. Corbett Avenue 34.701944 - 77.150556
Highway/Street Latltude(decimal degrees) Long itu d e(decimal degrees)
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.8
00
6. Amount of fee enclosed: $ 200.. The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Barden Lanier E-mail Address [e-mail]
Phone: Office # 910-455-3889
Mobile #
Landowner(s) of Record (attach accompanied page to list additional owners):
Keystone Contractors, Inc. 910-455-3889
Name
239 New Bridge Street
Current Mailing Address
Jacksonville NC 28540
City State
10. Deed Book No. 4494
Phone: Office #
239 New Bridge Street
Current Street Address
Jacksonville
Zip City
Page No. 963
Mobile #
NC 28540
State
Zip
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(les).
Keystone Contractors, Inc. [e-mail]
Company Name E-mail Address
239 New Bridge Street 239 New Bridge Street
Current Mailing Address Current Street Address
Jacksonville NC 28540 Jacksonville NC 28540
City State Zip City State Zip
Phone: Office # 910-455-3889 Mobile #
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:
Barden Lanier [e-mail]
Name of Registered Agent
239 New Bridge Street
Current Mailing Address
Jacksonville NC 28540
City State Zip
Phone: Office # 910-455-3889
E-mail Address
239 New Bridge Street
Current Street Address
Jacksonville NC
City State
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
28540
Zip
(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 an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Barden Lanier President
Type or print name
Signature
Title or Authority
S / 2 S/ 2.-�'
Date
a Notary Public of the County of [) I jl 0 Q
State of North Carolina, hereby certify that ile . LQS 1 `e)C appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
witnes�klfy llwr� pft# ptaria) seal, this day of , 20 �- g-
FF��
_ - Notary
p1-`� c, �j " Do's. 0 �'� My commission expires � � �
/;isZOW,
CO\ ,�\

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Benchmark Development Corporation 910-455-3889
Name Phone: Office # Mobile #
239 New Bridge Street 239 New Bridge Street
Current Mailing Address
Jacksonville NC
City State
Deed Book No. 2139
Landowner 3 of Record:
Name
Current Street Address
28540 Jacksonville NC 28540
Zip City State Zip
Page No._ 747 Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No._ _ Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Current Mailing Address
City State
Deed Book No._ .
Landowner 5 of Record:
Phone: Office #
Mobile #
Zip City State Zip
Page No. Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address Current Street Address
City
Deed Book No.
Mobile #
State Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Benchmark Development Corporation
Company 2 Name
239 New Bridge Street
Current Mailing Address
Jacksonville NC
City . State
Phone: Office # 910-455-3889
Company 3 Name
Current Mailing Address
City
Phone: Office #
Company 4 Name
[e-mail]
E-mail Address
239 New Bridge Street
Current Street Address
28540 Jacksonville NC
Zip City State
Mobile #
E-mail Address
Current Street Address
28540
Zip
State Zip City State Zip
Mobile #
Current Mailing Address
City State
Phone: Office #
Company 5 Name
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State
Mobile #
E-mail Address
Current Street Address
Zip City
Mobile #
State
Zip
Zip