NCC221082_FRO Submitted_20220318

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
F
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 Environment and Natural Resources. (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.
1, Project Name Long Point Reserve
Location of land -disturbing activity: County Moore City or Township Vass
Highway/Street SR1864 Latitude 35-08'31"N Longitude 79-09'49"W
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered {including off -site borrow and waste areas): 8.14 Ac
6 Amount of fee enclosed: $900.00 The application fee of $100.00 per acre (rounded up to the next
acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
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 Lee Humphrey E-mail Address LeeQdoubledeng.com
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Moore HL Properties LLC 910-690-5598
Name Telephone Fax Number
55 Walnut Creek Drive
Current Mailing Address Current Street Address
Pinehurst, _ _ NC 28374
City State Zip City State Zip
10. Deed Book No. 5531 Page No, 385 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Moore HL Properties, LLC
Name
55 Walnut Creek Drive
Current Mailing Address
ToMb22inehurstautomall.com
E-mail Address
Current Street Address
Pinehurst NC 28374
City State Zip City
State Zip
Telephone [phone] Fax Number NIA

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 State Zip
Telephone
E-mail Address
Current Street Address
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 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.
Tom Holderfield
Type or print name
0^�
Signature
Statb-bf North Carolina
personally before me
executed by him.
Managing Partner, Moore HL Properties, LL,C
Title or Authority
Date
qwu , a Notary Public of the County of MW(.L
hereby certify that ( A-0c"j-&—to appeared
this day and being duly sworn acknowledged that the above form was
Witness my hand and notarial seal, this d�
tAtO
A
} U� 00 i
My commission expires 7 - �,I- eV-e'j9