NCC222829_FRO Submitted_20220818

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 N/A in the blank.)
Part A.
1Project Name Derby Park - Phase Seven
.
2. Location of land -disturbing activity: County Craven City or Township New Bern
Highway/Street Elizabeth Ave Latitude 35 07 51 N Longitude -77 06 41 W
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25.0 acres
1,625.00 This is for an initial transfer, fees paid previously)
6. Amount of fee enclosed: $ . 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bobby Billingsley
E-mail Address [e-mail]
Telephone [phone]
p
Cell # Fax # [phone].636.2448
9. Landowner(s) of Record (attach
accompanied page to list additional owners):
Phoenix Derby Park, LLC
704.575.0323 n/a
Name
Telephone Fax Number
108 Mary Mack Lane
108 Mary Mack Lane
Current Mailing Address
Current Street Address
Fort Mill SC
29715 Fort Mill SC 29715
City State
Zip City State Zip
3723
1992
10. Deed Book No.
Page No. Provide a copy of the most current deed.
Part B.
1. 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):
Phoenix Derby Park, LLC
[e-mail]
Name
E-mail Address
108 Mary Mack Lane
108 Mary Mack Lane
Current Mailing Address
Current Street Address
Fort Mill SC
29715 Fort Mill SC 29715
City State
Zip City State Zip
Telephone p 704 .575 . 0323
Fax Number n/a

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:
Alexander Ricks, PLLC
Name
1420 E. 7th Sreet, Suite 100
[e-mail]
E-mail Address
1420 E. 7th Sreet, Suite 100
Current Mailing Address Current Street Address
Charlotte NC 28204 Charlotte NC 28204
City
State Zip City
Telephone [phone]
Fax Number
State
704.365.3676
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.
E-mail Address
Current Street Address
State 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.
Kristidan 1 gg Member & Manager - Phoenix Derby Park, LLC
Type r�7
Title or Authority
SignatYjre Date
I, r, fir. , a Notary Public of the County of
5o,:A
State of+forHrCarolina, hereby certify that Kris IGY1 1(CJLOtU appeared
personally before me this day and being duly sworn acknow ed that the above form was
executed by him.
Witness q(:kandjand notarial seal, this day of 20
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