NCC215708_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. Galvin's Ridge Phase 2A
1. Project Name
2. Location of land -disturbing activity: County Lee City or TownshipSanford
Highway/Street Colon Rd/US 1 Latitude 35d34'00" _ Longitude 79d09'30"
3. Approximate date land -disturbing activity will commence: 10/112021
4. Purpose of development (residential, commercial, industrial, institutional, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 39
6. Amount of fee enclosed: $2,535 . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Larry Moser E-mail [e-mail]
Telephone [phone] cell # 424-710-3709 Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Galvins Ridge Landco 251-850-5188
Name Telephone Fax Number
9794 Timber Cir Same
Current Mailing Address Current Street Address
Daphne AL 36526 Same
City State Zip City State Zip
10. Deed Book No. 01577 Page No. 0454 - 0536 provide a copy of the most current deed.
Part B.
1. 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.
Galvins Ridge Landco [e-mail]
Name E-mail Address
9794 Timber Cir Same
Current Mailing Address Current Street Address
Daphne AL 36526 Same
City State
Telepiione251-850-5188
Zip City
Fax Number
State
Zip

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:
Karen McKeown [e-mail]
Name
212 S. Tryon St, Ste 1000
Current Mailing Address
Charlotte, NC 28281
City
E-mail Address
212 S. Tryon St, Ste 1000
Current Street Address
Charlotte, NC 28281
State Zip City
Telephone[phone]
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.
P'0_Uter
R ype o,� print name
Signature
--------------------------------------------------------------
Member
Title or Authority
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Date
I, yt7'YfA a Notary Public of the &=of }tom 4-of f-
at is hereby certify that j4yc wJok 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 'ZG day of ��v� , 20 2
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