NCC224069_FRO Submitted_20221212

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 Name Hanover Pines Nature Park
2. Location of land -disturbing activity. County New Hanover City or Township
6101 Carolina Beach Road 34.1178-77.8980
Highway/Street _ Latitude�a�mar degrees) Longitudela�rmai a�e�,
3. Approximate date land -disturbing activity will commence:12-5-2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): public }dark
5. Total acreage disturbed or uncovered (Including off -site borrow and waste areas):6 _
6. Amount of fee enclosed: $4,300 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Exam pie: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑c Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tara Duckworth E-mail Address [e-mail]
Phone: office # 910-798-7635 Mobile # _
7
Landowner(s) of Record (attach accompanied page to list additional owners):
New Hanover County 910-798-7635
Name Phone: Office # Mobile #
230 Government Center Drive 230 Government Center Drive
Current Mailing Address Current Street Address
Wilmington, NC 28403 Wilmington, NC 28403
city State Zip City State up
10. Deed Book No.5330 _ _ Page No.1661 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.) U 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).
New Hanover County
Company Name
230 Government Center Drive Suite 195
Current Mailing Address
_Wilmington, NC 28403
City State Zip
Phone: Office # 910-798--7161
Iwu rtzbacher@n hcgov.com
E-mail Address
230 Government Center Drive
Current Street Address
City State Zip
Mobile #
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
Current Mailing Address
City
Phone. Office #
Current Street Address
State 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 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 attomey-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.
Lisa Wurtzbacher _ Assistant County Manage_ r
Se or print name Title or Authority
Signature Date
I, !, a Notary Public of the County of
State of North Carolina, hereby certify that 4: ' U 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, this day of , 24 a�
IYI
WL'd d, q4�&�
Notary
TAq� `A
% My commission expires „,

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.
Landowner 2 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State ?rp City State Zip
Deed Book No. _ Page No.� Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City State
Deed Book No.__
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No.
Phone: Office #
Current Street Address
Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Phone; Office # Mobile #
Current Street Address
State Zip City
Page Na.�
Landowner 5 of Record:
Name
Current Mailing Address
City State
Deed Book No.
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
Zip city State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 9 in Part B of the Financial Responsibllify/Ownership l=orm for multiple parties.
Attach copies of this page as needed to list all frnanclally responsible parties.
Company 2 Name
Current Mailing Address
City Sta
Phone: Office #
Company 3 Name
Current Mailing Address
City State
Phone: Office # _
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
Zp City State Zip
Mobile #
Company 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
Phone: Office # Mobile #
State
Zip