NCC223739_FRO Submitted_20221103

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 N/A in the blank.)
Part A.
1. Project Name Pinehurst Resort & Country Club Parking Terrace
2. Location of land -disturbing activity: County Moore City or Township Pinehurst
Carolina Vista 35.1897263°-79.4696644°
Highway/Street_ LatltUde(decimaldegrees) Long ltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence: October 1 5th, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.62
6. Amount of fee enclosed $ 1 ,400 . 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, afterwhich 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Calvin Burkley
Phone: Office # 910-295-6811
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pinehurst, LLC 910-295-6811
Name
PO Box 4000
Current Mailing Address
Pinehurst
City
NC 28374
910-986-3038
Phone: Office # Mobile #
210 Beulah Hill Rd
Current Street Address
Pinehurst NC 28374
State Zip City
State
Zip
10. Deed Book No. 1418 Page No. 402 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Pinehurst, LLC
Company Name
PO Box 4000
[e-mail]
E-mail Address
210 Beulah Hill Rd
Current Mailing Address Current Street Address
Pinehurst, NC, 28374 Pinehurst NC 28374
City State Zip City State Zip
Phone: Office # 910-295-6811 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:
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 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.
N/A
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
LKC Engineering
Engineering firm or other consultant
Philip Picerno
Individual contact person (type or print)
[e-mail]
E-mail Address
910-420-1437
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
Calvin B
Typ or int na
Signature
Director of Projects and Planning
Title or Authority
/ 0 Z�/z Z_
Date
I, Log ( Kcs k a Notary Public of the County of 1 Y 1 "-LLJ .__
State of North Carolina, hereby certify that (2 A L 0 t1 rEl e _ appeared personally
before me this day and being duly sworn acknowledged that the above m was executed by him/her
Witness my hand and notarial seal, this 'I day of ©i6 , 20 ZZ
Notary �� A
Seal My commission expires �cib &z, 3! a 3
*\�, jN% A
Notary Public
Moore
County
My Comm. Exp.
2 02-03.2023 Q-
nnnn0

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.
Name
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 3 of Record:
Name
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
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 5 of Record:
Name
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.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
State Zip
State Zip
State Zip
City State Zip City State Zip
Phone: Office # Mobile #