NCC220889_FRO Submitted_20220224

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. Automotive Maintenance Shop - EEB Holdings, LLC.
1. Project Name
2. Location of land -disturbing activity: County Cumberland City or Township Pearces MITI
Highway/Street Camden Road Latitude 35.0047 Longitude-78.9209
3. Approximate date land -disturbing activity will commence: Mid February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.98
6. Amount of fee enclosed: $ 500.00 The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900,00).
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 Ben Borger E-mail [e-mail]
M
Telephone [phone]
Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
EEB Holdings, LLC. 408-712-0245
Name
Teiephone Fax Number
7357 Mariners Landing Drive
7357 Mariners Landing Drive
Current Mailing Address
Current Street Address
Fayetteville NC 28306
Fayetteville NC 28306
City State Zip
City State Zip
10. Deed Book No. 11153 Page No. 126 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
EEB Holdings, LLC.
[e-mail]
Name
E-mail Address
7357 Mariners Landing Drive
7357 Mariners Landing Drive
Current Mailing Address
Current Street Address
Fayetteville NC 28306
Fayetteville NC 28306
City State Zip
City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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). I agree to provide
corrected information should there be any change in the information provided herein.
Ben Borger
Type or print name
l
Si ature
Member/Manager - EEB Holdings, LLC.
Title or Authority
Date
1, �t� wvv� 0 ("Ad CA , a Notary Public of the County of
State of North Carolina, hereby certify that or !�I JPW '"- appeared
personally before me this day and being duly sworn OcknOwl4dged that the above form was
executed by him.
Witness my hand and notarial seal, this day of 20
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