NCC231664_FRO Submitted_20230602

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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
e been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (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.
1. Project Name Share the Table
2. Location of land-disturbing activity: County Pender City or Township Topsail Township
Highway/Street US HWY 17 Latitude 34° 28' 10"N Longitude 77° 34' 55" W
3. Approximate date land-disturbing activity will commence: April, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.75
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: a 9-acre application fee is $900).
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 Mike Afifv E-mail Address mmafify(c�gmail.com
Telephone [phone] Cell# 919-210-9474 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Share the Table 910-616-897
Name Telephone Fax Number
P.O. Box 4170 12395 NC 50
Current Mailing Address Current Street Address
Hampstead NC 28443 Hampstead NC 28443
City State Zip City State Zip
4740 632
10. Deed Book No. 4768 Page No. 2931 Provide a copy of the most
current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Share the Table sharethetablenc(a�gmail.com
Name E-mail Address
P.O. Box 4170 12395 NC 50
Current Mailing Address Current Street Address
Hampstead NC 28443 Hampstead NC 28443
City State Zip City State Zip

Telephone [phone] Fax Number
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 ZipCity Y 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.
Dawn Ellis Registered Agent—Share the Table
Type or print name Title or Authority
j1 --c_Zz
Signature Date
/CPte-/ , a otary Public of the County of Oa) f-61A-or/e-✓'
State of North Carolina, hereby certify that / C/1i,S appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this % day of Mi6712--4-tv 20 27
Notary
_ Seal
= My commission expires