NCC222812_FRO Submitted_20220808

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 NIA in the blank.)
Part A.
1. Project Name Cambridge Southeast Estates
2. Location of land -disturbing activity: County Chatham City or Township Siler City
SR 1108/Ramp Stone Roar! 35.74111-79.4838
Highway/Street Latitudet�ec�ma� degrees) LOngltlJde(decimal degrees)
3. Approximate date land -disturbing activity will commence: 06-06-2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.54 + 0.46 = 6.0
6. Amount of fee enclosed: $ 600.00 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 ❑ No ❑R
M
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
E-mail Address
Name
David H. Blevins, P.E. [e-mail]
Phone: Office # Mobile #
919-851-4422 919-880-2944
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cambridge Southeast, LLC. 805-937-9479
Name
650 E. Clark Avenue
Current Mailing Address
Orcutt CA 03455
City State
10. Deed Book No. 1900
Phone: Office # Mobile #
Current Street Address
Zip City
Page No. 0738
State
Zip
Provide a copy of the most current deed.

Part B.
1. 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 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).
Cambridge Southeast, LLC. [e-mail]
Company Name
650 E. Clark Avenue
Current Mailing Address
Orcutt CA 03455
City State
Phone: Office #
805-937-9479
E-mail Address
Current Street Address
Zip City
Mobile #
State
Zip
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:
Cambridge Southeast, LLC. [e-mail]
Name of Registered Agent E-mail Address
650 East Clark Ave.
Current Mailing Address Current Street Address
Orcutt CA 93455
City
State
Phone: Office # 805-937-9479
David Wilson
Zip City
Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
David Wilson [e-mail]
Name of Registered Agent E-mail Address
1173 Box Car Way 1173 Box Car Way
Current Mailing Address
Apex NC 27502
City
State
Current Street Address
Apex NC 27502
Zip City
Phone: Office # 805-937-8479 Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
State Zip

A notary public or other officer completing this cerHicate
w,,M es only the identity of the individual who signed the
document to .,::,ich t`ris certificate is attached, and not
,e truthfulmss, accuracy, orvalidilycfthat dicurrent.
(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
corrected information should there be any change in the information provided herein.
David Wilson
name
Managing Member
Title or Authority
_z'�rzz
Date
I, 'TG)v� (b hi Eta!► A , a Notary Public of the County of %11h
CG �rfv�-�,�� r. �.
State of No tgz;Zel+�a, hereby certify that 1,✓ ` appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 79/ day of A'I , 20 -1'L
Notary
My commission expires 12 /uZe7u2 L
JASON Cisco ESPINOZA
COMM. #2269358
NOTARY PUBLIC . CALIFORNIA
SANTA BARSARA COUNTY
Nh Comm, EON t')ecember 2, 2022

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. -
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 3 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 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
Name
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
State Zip
Provide a copy of the most current deed.

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.
Van Ness Apartments, LLC [e-mail]
Company 2 Name E-mail Address
650 East Clark Avenue
Current Mailing Address Current Street Address
Orcutt NC 93455
City State
Phone: Office # 805-937-9479
Deed Book No. 1290 Page No. 0812
Company 3 Name
Current Mailing Address
City State
Phone: Office #
Company 4 Name
Current Mailing Address
City State
Phone: Office #
Company 5 Name
Current Mailing Address
City State
Phone: Office #
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
Zip City State
Mobile #
E-mail Address
Current Street Address
Zip City State
Mobile #
E-mail Address
Current Street Address
Zip City State
Mobile #
Zip
Zip
Zip

VAN NESSAPARTMENTST LLC
650 East Clark Avenue
ORCUTT, CA 93455
Phone [phone]
Fax [phone]
October 5, 2018
RE: Letter of Consent
Cambridge Southeast Estates Mobile Home Park Expansion
Siler City, NC
CHATH-2019-001
To Whom it may concern:
As the managing member for Van Ness Apartments, LLC; I am the financially
responsible party for the parcel identified as Pin #8752-04-64-8361. I am giving
permission for access and land disturbing activity on the property owned by Van Ness
Apartments, LLC for the construction of the Cambridge Southeast Estates Mobile Home
Park on the adjoining property owned by Cambridge Southeast, LLC. If you have any
questions; please call my office.
fiber