NCC240450_FRO Submitted_20240216

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Southern Public Works Department
140 Memorial Park Court
Pines Southern Pines, North Carolina 28387
Telephone: [phone]— Fax: [phone]
No person may initiate any land-disturbing activity greater than 30,000 sq. ft. (including lots or tracts of land that are
a part of a Common Plan of Development that the total disturbance will exceed 30,000 sq.ft.)as covered by the
Town's Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been
completed and approved by the Town of Southern Pines. (Please type or print and, if the question is not applicable
or information unavailable, place N/A in the blank.)
Part A.
1. Project Name: Morganton Park South - Phase 3 (BJ's Wholesale/Starbucks)
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address Southern Road
3. Latitude: 35.170 Longitude: -79.419 PIN: Part of 857100681141
4. Percent Impervious: 60%
5. Approximate date that land-disturbing activity will commence: February 2024
6. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 17
8. Amount of fee enclosed: $ 2,700
The application fee is$300.00 for the first acre plus$150.00 for each additional acre, or part thereof.
The revised plan review fee is$50 for each submittal after the 2nd review.
Any substantial revision to a previously approved, active plan is $50 per acre, or part thereof.
No Fee for Minor Construction Activities less than 30,000 sq. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dave Woodke- Director of Construction E-mail Address [e-mail]
Telephone [phone] Cell# 513-508-7951 Fax# [phone]
10. Landowner(s)of Record (attach accompanied page to list additional owners):
MSP Retail II, LLC 513-792-5000 513-792-5010
Name Telephone Fax#
8044 Montgomery Road, Suite 370 SAME
Current Mailing Address Current Street Address
Cincinnati, Ohio 45236 SAME
City State Zip City State Zip
6112
11. Deed Book No. Page No. 408 (Provide a copy of the most current deed).

Part B.
1. Person(s) or firm(s)who is financially responsible for the land-disturbing activity
(Provide a comprehensive list of all responsible parties on an attached sheet):
MSP Retail II, LLC [e-mail]
Name E-mail Address
8044 Montgomery Road, Suite 370 SAME
Current Mailing Address Current Street Address
Cincinnati, Ohio 45236 SAME
City State Zip City State Zip
Telephone [phone] Fax# [phone]
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:
National Registered Agents, Inc.
Name of Registered NC Agent E-mail Address
160 Mine Lake Ct., Suite 200 SAME
Current Mailing Address Current Street Address
Raleigh, NC 27615 SAME
City State Zip City State Zip
Telephone Fax#
(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 NC Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax#

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 informationor� provided hereirk
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I, /7�,/*� Ak4;9,h4t. , a tary Public off� the County of //G .�'
State of e- = - : :, hereby certify that t2ort,-/ 19-2/'._
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 /ry
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4..�� , MELONNA RAE Rf7CHIE•SPAHNI �frt
. rnNotary Public
_ YT ° State of Ohio
v ..;_ Y My Comm.Expires Notary
Seal" 0 May 18,2026 / /��,
My commission expires lccx2 2$
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes El No El
REVISED:January 9,2020