NCC223017_FRO Submitted_20220913

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 NIA in the blank.)
Part A.
1. Project NameSite Development Plan for Curtin Realty & Investments, LLC.
2. Location of land -disturbing activity: County. Robeson City or TownshipLumberton
Hi hwa JStreetThompson Rd. 34.589 _79.09"
9 Y Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Upon Approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):16
6. Amount of fee enclosed: $1,600.00 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 Buddy Curtin E-mail [e-mail]
Phone: Office # 704-575-5647 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Curtin Realty & Investments LLC. 704-575-5647
Name Phone: Office # Mobile #
P.O. Box 38220 11900 Goodrich Drive
Current Mailing Address Current Street Address
Charlotte NC 28278 Charlotte NC 28273
City State Zip City State Zip
10. Deed Book No.2331 page No.710 Provide a copy of the most current deed.

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(ies).
Curtin Realty & Investments, LLC
Company Name
PO Box 38220
Current Mailing Address
Charlotte NC 28278
City State Zip
Phone: Office # 705-575-5647
[e-mail]
E-mail Address
11900 Goodrich Drive
Current Street Address
Charlotte NC 28273
City State Zip
Mobile # [phone]
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:
Katherine Lie
Name of Registered Agent
15423 Cimarron Hills Ln
Current Mailing Address
Charlotte NC 28278
City
State
Phone: Office # 705-575-5647
[e-mail]
E-mail Address
15423 Cimarron Hills Ln
Current Street Address
Charlotte NC 28278
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State 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
Current Mailing Address
E-mail 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 inbusiness under anassumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is on individual, General
Partnership, or other company not registered and doing business under an assumed name, affach a copy
ofthe Certificate ofAssumed Name.
Company DBA Name
The above information iatrue and correct tothe best ofnlyknowledge andbeliefmndvxooprovided
bxnleunder oath. (This form must basigned bxtheFinmnCje|k/ ResponsiblePerson ifnnindividua|bd
or his mttorney-in-hact, or if not an |ndk/|dua|, by an cdfimar, director, poAner, or registered oQentxfith
the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected information should there be any change inthe information provided herein.
Katherine Lie OVVO8r
Type or print h name
WE7-�
Signature
Title or Authority
7/13/22
Date
[ a Notary Public of the County of

Continued from Items 9&/O/nPart Aofthe Financial ResponsibilitylOwnership Form for
multiple
omv/*rn Attach copies �needed talandowners.
Landowner of Record:
Name
Phone: Office # Mobile
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No
Provide mcopy ofthe most current deed.
Landowner 3ofRecord:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide ocopy ofthe most current deed.
Landowner 4ofRecord:
Name
Phone: Office Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide acopy ofthe most current deed.
Landowner 5ofRecord:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide acopy of the most current deed.

Continued from Item I in Part B of the Financial ResponsibilitylOwnership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #