NCC230385_FRO Submitted_20230213

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 Tidal Wave Auto Spa Washington @ Carolina Ave
2.
Location of land -disturbing activity: County Beaufort
City or Township Washington
Highway/Street Carolina Ave LatltUde(dedmal degrees) 35 561156 Longitude(decimal degrees) -77061928
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.39
6. Amount of fee enclosed: $ 200 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 Alex Perry E-mail Address [e-mail]
Phone: Office #
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Washington ARD CGP LLC
Name
361 Summit Blvd
Current Mailing Address
Birmingham, AL 35243
City State
10. Deed Book No. 2093
Phone: Office #
Current Street Address
Zip City
Page No. 721
Mobile #
State
91
Provide a copy of the most current deed.

Part B.
i 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 sore proprietorship or if the landowner(s) is
an indivldual(s), the names) of the owner(s) may be listed as the financially responsible parly(ies).
TWAS Properties, LLC
Company Name
115EMain S
Current Mailing Address
Thomaston, Georgia 30286
City State Zip
Phone: Office #
[e-mail]
E-mail Address
115 E Main S
Current Street Address
Thomaston, Georgia 30286
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:
Name of Registered Agent
Current Mailing Address
U Ity
Phone: Office #
State Zip
E-mail Address
Current Street Address
City State
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
Z-1N
(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:
CT Corperation System
Name of Registered Agent
160 Mine Lake CT, STE 200
Current Mailing Address
Raleigh, North Carolina 27615
City State Zip
Phone: Office #
Martie Murphy
[e-mail]
E-mail Address
160 Mine Lake CT, STE 200
Current Street Address
Raleigh, North Carolina 27615
City State Zip
Mobile # [phone]
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.
-f—, m',e m .5#A
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.
cat. r- �Oh U
Type or p i name Title or Authority
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Signature Date
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------------------------_----------- —--------- --------------------
I a Notary Public of the County of
.�
State of Y hereby certify that �&6f-mupkvappeared personally
before me this day and being duly sworn acknowledged that the a ove form was executed by him/her.
Witness my hand and notarial seal, this 2#— day of DC66VV1' XA , 20��
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Q• �apiA��'•. w Notary
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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
Current Mailing Address
City
Deed Book fro._
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
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.

E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
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 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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
State Zip