NCC220189_FRO Submitted_20220111

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disi:urbing activity an oh6 or, more acres as covered by the Aet 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. Collar Tree at Joynees Crossing
1. Project Name
2. Location of land -disturbing activity: County Nash City or Township Rocky Mount Outside
Highway/Street NC Hwy 97 Latitude 35.893244 Longitude -77.861872
3. Approximate date land-dlsturbing activity will commence: Winter 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.2 AC
6. Amount of fee enclosed: $195.00 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:
Nameyid Rosenberg E-mail Address [e-mail]
Telephone [phone] cell # 864-363-2274 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Red Oak Farms Development, LLC 252-904-0383 N/A
Naive Telephone Fax Number
5088 Oak Level Road Same
Current Mailing Address Current Street Address
Rocky Mount NC 27804 Same
City State Zip City State Zip
10. Deed Book No. 3141 Page No. 200 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.
Browning Rocky Mount, LLC [e-mail]
Name E-mail Address
P.O. Box 25683 Same
Current Mailing Address Current Street Address
Greenville SC 29616 Same
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
CT Corporation System
Name
160 Mine Lake Court Suite 200
Current Mailing Address
Raleigh NC 27615
City
Telephone [phone]
E-mail Address
160 Mine Lake Court Suite 200
Current Street Address
Raleigh NC 27615
Zip 'City
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:
NIA
Name of Registered Agent
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
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 attomey-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.
Rosenberg as Manager for Browning Rocky Mount LLC
or Tint na Title or Authority
GARS (� 11/23/2021
Si ature Date
MA-r: ovt M. d v jt •ta , , a Notary Public of the County of
A MV—
State of Borth Carolina, hereby certify that T)ay. A. I2. J2a_v"e v 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 Z 3 day of 20 L !
.`� t%M C Cp
�T• �aTAR� = �L Notary
Seal - .►n-y.
AUSt_�G My commission expires 4' 16 .3 O