NCC215729_FRO Submitted_20211014

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.
Project Name Mason Lumber Yard Subdivision
2. Location of land -disturbing activity: County Beaufort City or Township Washington
Highway/Street US HWY 264 Latitude 35°34'06" Longitude-77004'48"
Approximate date land -disturbing activity will commence: 8/1/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 William H. Page E-mail Address whpagejr(agmail.com
Telephone [phone] Cell # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
William H. Page Trust 252-946-8159
Name Telephone
PO Box 1828
Current Mailing Address Current Street Address
Washington NC 27889
City State Zip
City
State
Fax Number
10. Deed Book No. 1739 Page No. 356 Provide a copy of the most current deed.
Part B.
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.
William H. Page Trust
Name
PO Box 1828
Current Mailing Address
Washington NC 27889
City State Zip
whpageir(a-gmail.com
E-mail Address
Current Street Address
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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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
Current Mailing Address
E-mail 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.
William H. Page Jr. Trustee
Type or print name Title or Authority
Signature V
Date
I, t�tt lSt(YICi A- CLkttitl a Notary Public of the County of
State of North Carolina, hereby certify that W 1 U ttm IA. 6Loc, UC . appeared
personally before me this day and being duly sworn acknowledgebl that the above form was executed
by him.
Witness my hand andx�,t is(� day of�DYt ` , 20 Z I
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6. Notary
Seal 4/c A
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