NCC223150_FRO Submitted_20220908

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 NIA in the blank.)
Part A.
1. Project Name: Townhomes on Bennett
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Highway/Street: Wisconsin Ave Latitude (decimal degrees) 35.170 Longitude (decimal degrees) -79.3 99
3. Approximate date land-disturbing.activity will commence: 30 Sept 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 1.04
6. Amount of fee enclosed $200. The Express Permitting application fee is a dual charge. The normal fee
of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks should be
addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ® Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Eric Givens E-mail Address: [e-mail]
Phone: Office # 910-688-7361
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bantembo, LLC 910-688-7361
Name Phone: Office #
P.O. Box 1872 30 Country Club Blvd
Current Mailing Address Current Street Address
r
Southern Pines NC 28388 Whispering Pines NC 28327
City State Zip City State Zip
10. Deed Book No.5732 Page No.158-161 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 names) of the owner(s) may be listed as the financially responsible party(ies).
Bantembo [e-mail]
Company Name E-mail Address
P.O. Box 1872 30 Country Club Blvd
Current Mailing Address Current Street Address
Southern Pines NC 28388 Whispering Pines NC 28327
City State Zip City State Zip
Phone: Office # 910-688-7361
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:
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)
b If 'the Fine ciall Responsible Pa ` ' '
h,• z."!? Y P Party is not a resident of North Carolina, give and skeet adr n ss',
e
of the de`sigriated North Carolina agent who is registered on the NC Secretary of Stateuslss tgitt;:,
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Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
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City
pf `,ys Mate Zip city to
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P one: Office #
Mobile #;�.a': �� gigg_, •,
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Ndmd of Individual to Contact (if Registered Agent is a company) .
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(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
(d) if order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering firm or other consultant
Individual contact person (type or print)
E-mail Address
Phone: Office #
Mobile #
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.
Colin Webster
Type or print name
(7�'_ -7
Signature
Manager
Title or Authority
6 -
Date
.�a Notary Public of the County of
State of North Carolina, hereby certify that -,v appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal,
03.20
this day of - 20
e' Notary
My commission expires'e�2L.