NCC230524_FRO Submitted_20230228

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Holly Shelter Shooting Range - Shotgun Range and Other Improvements
1. Project Name
2. Location of land -disturbing activity: County Pender City or Township Rocky Point
Highway/Street 8718 Shaw Highway Latitude 34-33-46 Longitude 77-48-15
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Shooting Range
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.6
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Steven Bailey E-mail Address [e-mail]
Telephone [phone] Cell # 919-618-9219 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NC Wildlife Resources Commission 919-707-0150 919-707-0162
Name Telephone Fax Number
1701 Mail Service Center 1751 Varsity Drive
Current Mailing Address Current Street Address
Raleigh NC 27699-1720 Raleigh NC 27606-2576
City State Zip City State Zip
10. Deed Book No. 2522 Page No. 0053 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
NC Wildlife Resources Commission [e-mail]
Name E-mail Address
1718 NC Hwy 56 1718 NC Hwy 56
Current Mailing Address
Creedmoor
City
Current Street Address
NC 27522 Creedmoor
State Zip City
NC 27522
State
Zip
Telephone [phone] Fax Number 919-528-2524

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
Fax Number
(b) If the Financially Responsible Party
is a Partnership or other person engaging in business under an
assumed name, attach a copy of the
Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone
Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Steven Bailey - NC Wildlife Resources Commission
Facility Construction Engineer
Type or print name Title or Authority
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Signature Da e
I, k�A� dLU)4 -- , a Notary Public of the County of V�'qev
State of North Carolina, hereby certify that S"1 eyt^- V /` t appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witnes�.!�,`bNfttarial seal, this day of J�tiw , 20
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