NCC220057_FRO Submitted_20220120

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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.
1. Project Name Carolina Colours Medical Park
2. Location of land -disturbing activity: County Craven City or Township New Bern
Highway/Street Waterscape Way Latitude 35.0294 Longitude -77.0098
3. Approximate date land -disturbing activity will commence: 12/15/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.00
6. Amount of fee enclosed: $ 1,750.00 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Mr. Terry Morris E-mail Address [e-mail]
Telephone [phone] cell # 252.670.6749 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
New Market HDS, LLC 910.239.5590 910.526.2171
Name Telephone Fax Number
1131-B Military Cutoff Road 1131-B Military Cutoff Road
Current Mailing Address Current Street Address
Wilmington, NC 28405 Wilmington, NC 28405
City State Zip City State Zip
10. Deed Book No. 2359 Page No. 855 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.
New Market HDS, LLC [e-mail]
Name
1131-B Military Cutoff Road
Current Mailing Address
Wilmington, NC 28405
City
E-mail Address
1131-B Military Cutoff Road
Current Street Address
Wilmington, NC 28405
State Zip City
State
Zip
Telephone [phone] Fax Number 910.256.2171

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip
City State Zip
Telephone
Fax Number
(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:
Jason D. Swain
[e-mail]
Name of Registered Agent
E-mail Address
1131-B Military Cutoff Road
1131-13 Military Cutoff Road
Current Mailing Address
Current Street Address
Wilmington, NC 28405
Wilmington, NC 28405
City State Zip
City State Zip
Telephone [phone]
Fax Number 910-256-2171
(c) In order to facilitate Express Permitting, it
is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
McKim and Creed
[e-mail]
Engineering Firm or other consultant
E-mail Address
Trae Livick
910.343.1048 910.251.8282
Individual contact person (type or print)
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 herein.
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Signature-'- Date
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State of North C rolina, hereby certify that J/`"dih 9MAI VI appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
V Witness my hand and notarial seal, thisy� day of � OV 91.y", 20�
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