NCC232672_FRO Submitted_20230907

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 Hood Swamp Site
2 Location of land-disturbing activity: County Wayne City or Township Princeton
483 Lassiter Rd 35.383928 -78.125685
Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
3 Approximate date land-disturbing activity will commence: November 1 , 2023
4 Purpose of development (residential, commercial, industrial, institutional, etc.): Restoration
5 Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8-6 acres
6 Amount of fee enclosed S 900.00 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 El No ❑
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Alex Baldwin E-mail Address [e-mail]
Phone: Office# 919-755-9490 Mobile# [phone]
9 Landowner(s) of Record (attach accompanied page to list additional owners)
Joe Thomas & Luby Raylon Mitchell 919-921-0490 919-921-0490
Name Phone: Office# Mobile#
2423 Old Smithfield Rd 2423 Old Smithfield Rd
Current Mailing Address Current Street Address
Princeton, NC 27569 Princeton, NC 27569
City State Zip City State Zip
10. Deed Book No. 1311 Page No 631 Provide a copy of the most current deed.

Part B.
1. Corn pany(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 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)
Restoration Systems LLC [e-mail]
Company Name E-mail Address
1101 Haynes St, Suite 211 1101 Haynes St, Suite 211
Current Mailing Address Current Street Address
Raleigh, NC 27604 Raleigh, NC 27604
City State Zip City State Zip
Phone: Office# 919-755-9490 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:
John Preyer [e-mail]
Name of Registered Agent E-mail Address
1101 Haynes St, Suite 211 1101 Haynes St, Suite 211
Current Mailing Address Current Street Address
Raleigh, NC 27604 Raleigh, NC 27604
City State Zip City State Zip
Phone: Office# 919-755-9490 Mobile# [phone]
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.
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
correcte info should there be any change in the information providedherein.
Type or print na e / Title or Authority
.3 -- 2-3
ig ture Date
I, Sin r Jr,..Y-.c" if o , a Notary Public of the County of Vat ki.
State of North Carolina, herebycerti that o -Y
fy ��n rcyyer/— appeared personally
before me this day and being duly sworn acknowledged tIdat the above form was executed by him/her.
Witness my hand and notarial seal, this . day of , 20 23
"NCAN ' tary
i=O;.'�OTARy'•2'W My commission expires_ lF-S Z(o
. -4 :
' -., �C,OUN`'C ��'��

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:
Joe Thomas & Luby Raylon Mitchell 919-921-0490 919-921-0490
Name Phone: Office# Mobile#
2423 Old Smithfield Rd 2423 Old Smithfield Rd
Current Mailing Address Current Street Address
Princeton, NC 27569 Princeton, NC 27569
City State Zip City State Zip
Deed Book No 997 Page No 132 Provide a copy of the most current deed
Landowner 3 of Record
Restoration Systems, LLC 919-755-9490 919-274-2419
Name Phone: Office# Mobile#
1101 Haynes Street, Suite 211 1101 Haynes Street, Suite 211
Current Mailing Address Current Street Address
Raleigh, NC 27604 Raleigh, NC 27604
City State Zip City State Zip
Deed Book No. 3757 Page No. 327 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 I in Part B 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 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 State Zip
Phone: Office# Mobile#