NCC223643_FRO Submitted_20221031

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 Red Collar Dog
2. Location of land -disturbing activity: County Camden City or Township Courthouse
U S 158 36.350916-76.147882
Highway/Street LatltUde(decimal degrees) LOnglfude(decimal degrees)
3. Approximate date land -disturbing activity will commence: 11 /1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.82 aC.
6. Amount of fee enclosed: $ 200.00 . 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 Ryan Cooper E-mail [e-mail]
Phone: Office # Mobile # [phone]
R1
Landowner(s) of Record (attach accompanied page to list additional owners):
The Red Collar Dog, LLC
Name
417D NC Hwy 343 N
Current Mailing Address
Camden NC 27921
City State
10. Deed Book No. 426
252-339-5478
Phone: Office # Mobile #
same
Current Street Address
Zip City
Page No. 545
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(ies).
The Red Collar Dog, LLC
Company Name
417D NC Hwy 343 N
Current Mailing Address
Camden NC 27921
City State Zip
Phone: Office #
[e-mail]
E-mail Address
same
Current Street Address
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:
United States Corporation Agents, Inc.
Name of Registered Agent
6135 Park South Drive Ste 510
Current Mailing Address
Charlotte NC 28210
City
E-mail Address
same
Current Street Address
State Zip City
Phone: Office # [phone] Mobile #
Nicole Miller
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 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.
Ryan Cooper
Type or print name
6
Manager
Title or Authority
ZZZ
Date
I, a Notary Public of the County of
State of North Carolina, hereby certify that \ irl V-\ l 'n o appeared personally
before me this day and being duly sworn ackno vlbdged that the above form was executed by him/her.
Witness my hand and notarial seal, this ��day of rAg (,�(,lSf 20Q^
\AB ES h,%� otar
Z ; ' p, R Y '•;�,c My commission expires
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