NCC220333_FRO Submitted_20220127

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. Dunn RV Park
1. Project Name
2. Location of land -disturbing activity: County Harnett City or TownshipDunn
Highway/Street NC 55 E Latitude 35.3024 Longitude-78.5892
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.); RV Park
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.29
6. Amount of fee enclosed: $3,300 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 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 $2,900). 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
13x140=1,300
8x250=2000
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jason R Bagwell E-mail [e-mail]
Telephone Cell # 919-618-1987 Fax# NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ropestar Events, LLC 919-618--1987
Name Telephone Fax Number
111 W Main Street Suite 202
Current Mailing Address Current Street Address
Garner NC 20529
City State Zip City State Zip
10. Deed Book No. 3732 Page No. 0821 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.
Ropestar Events, LLC [e-mail]
Name E-mail Address
111 W Main Street Suite 202
Current Mailing Address Current Street Address
Garner NC 27529
City
State Zip City
Telephone [phone] 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:
NIA
NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA NIA NIA
NIA NIA NIA
City State Zip
City State Zip
Telephone NIA
Fax Number N/A
(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
NIA
Name of Registered Agent
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA NIA NIA
NIA NIA NIA
City State Zip
City State Zip
Telephone NIA
Fax Number NIA
(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:
Adams & Hodge Engineering, PC
[e-mail]
Engineering Firm or other consultant
E-mail Address
Eva King, PE
980-253-5773 NIA
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 provided herein.
Jason R Bagwell
Managing Member
Type o t= Title or Authority
Si natur Date
-------------------------------------
I, C` o 1 � cxy­�CJ _R AA'arY1N, a Notary Public of the County of
State of North Carolina, hereby certify that '�� M appeared personally
before me this day and being duly sworn acknowledged that the abovb orm was executed by him.
Witness my hand and notarial seal, this 30 day of 201�)l
CA"-) -t. Dja:�_3
Notary
Ffotary Publliic s `l I
Johnston County My commission expires 1 a i ` - c�l� I
M Commisslon g a2sna 0-1 I-20.