NCC220589_FRO Submitted_20220207

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.
1. Project Name Owen Park Subdivision, Phase 1
2. Location of land -disturbing activity: County Alamance City or Township Gibsonville
Highway/Street Aspen Ave. Latitude 36.090184 Longitude -79.532475
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 39.3
6. Amount of fee enclosed: $ 2,600 . 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 Matt Kirkpatrick E-mail Address [e-mail]
Telephone Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Owen Park Associates, LLC [phone]
Name Telephone Fax Number
4004 Barrett Dr., STE. 204 4004 Barrett Dr., STE. 204
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
City
10. Deed Book No.
Part B.
State
3956
Zip City
Page No. 0173
State
ME
Provide a copy of the most current deed.
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.
Owen Park Associates, LLC [e-mail]
Name
4004 Barrett Dr., STE. 204
E-mail Address
4004 Barrett Dr., STE. 204
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
City
State Zip City
State
ME

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 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip
Telephone.
City
Fax Number
State Zip
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). 1 agree to provide
corrected information should there be any change in the information provided herein.
Matt Kirkpatrick
Type or print name
Signat e
Managing Member
Title or Authority
Date
1, IV) a(-, Or Y' e chn," t'S , a Notary Public of the County of WG
State of North Carolina, hereby certify that ��)CA� 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 ��_day of A 20 �-
MARJORIE A. IAMBRAKIS
NOTE%RY PUBLIC
WAF KE COUNTY, NC
My Coin Expires 6 20 2022
Notary U //
My commission expires