NCC220752_FRO Submitted_20220215

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 3845 Conlon Way
2. Location of land -disturbing activity: County_ Pasquotank City or Township_ Elizabeth City
3
Highway/Street Conlon Way _ Latitude 36.294344 Longitude-76.293263
Approximate date land -disturbing activity will commence:_ January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.16
6. Amount of fee enclosed: $ 130.00 . 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 X No Enclosed_ X
8
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Greg Nigro E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
TGW 1 North, LLC [phone]
Name Telephone
401 W. Ontario, Suite 400 same as mailing
Current Mailing Address
Chicago, IL 60654
., .y
10. Deed Book No. 1223
Part B.
1
Current Street Address
State Zip City
Page No. 313
State
Fax Number
Zip
Provide a copy of the most current deed.
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.
3845 Conlon, LLC [e-mail]
Name E-mail Address
PO Box 2084 2420 S. Croatan Highway
Current Mailing Address Current Street Address
Kitty Hawk, NC 27949 Nags Head, NC 27959
City State Zip City State Zip

Telephone_(252) 489-4677
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 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.
Greg Nigro Manager
Type or print name Title or Authority
co -
Sig a Date
1. �n�i c. M U , a Notary Public of the County of
State of North Carolina, hereby ce CA i0 appeared
personally before me this day and being duly sworn ackrtdwledged th t the above form was executed
by him.
Witness my hand and gglarrait",g I, this day of �G �� 20 2
�P NOtary Pubu, 0 's
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Se6t MY Comm. JExp. — W U p 0-22-2025 My commission expires
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