NCC221312_FRO Submitted_20220405

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Dugout Stream and Wetland Mitigation Site
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Upton Tyson Rd. 34.929721 -78.851233
Highway/Street _ LatltUde(decimaldegrees) Long ltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence: June 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Ecological Restoration
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 33.4
6. Amount of fee enclosed: $ 3,400.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Paul Dunn E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Vance U Tyson Jr.
Name Phone: Office # Mobile #
4925 NC Hwy 87 South
Current Mailing Address Current Street Address
Fayetteville NC 28306
City State Zip City State Zip
10. Deed Book No. 11063 Page No. 0518 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Resource Environmental Solutions, LLC [e-mail]
Company Name
3600 Glenwood Ave, Suite 100
Current Mailing Address
Raleigh NC 27612
E-mail Address
3600 Glenwood Ave, Suite 100
Current Street Address
Raleigh NC 27612
City State Zip City State Zip
Phone: Office # 919-209-1064 Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Daniel Ramsay
[e-mail]
Name of Registered Agent
E-mail Address
3600 Glenwood Ave, Suite 100
3600 Glenwood Ave, Suite 100
Current Mailing Address
Current Street Address
Raleigh NC 27612
Raleigh NC 27612
City State Zip
City State Zip
Phone: Office # 919-209-1064
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a
resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Daniel Ramsay General Manager
Ty or print name Title. or Authority
Signature Date
---------------------------------------------------------------------------------------------------------------------------------
I, A1'Y q l �� , a Notary Public of the County of WAk ',
State of North Carolina, hereby certify that �[' ►'1 l 6 1 & -J�A�X _appeared personally
before me this day and being duly sworn acknowledged that the above for as executed by him/her.
Witness my hand and notarial seal, this
AMY STALEY
NOTARY PUBLIC
Johnston County
c¢q� rth Carolina
My CorrTrtfi ion Expires Sept. 4, 2023
day of 'via rG�1 , 20 Z 2-
Notary U My commission expires rrp_�, II -- 1 1 >>
7 V 1rT 202 7

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to
list all landowners.
Landowner 2 of Record:
Vance U Tyson Jr.
Name
Phone: Office # Mobile #
4925 NC Hwy 87 South
Current Mailing Address
Current Street Address
Fayetteville NC 28306
City State Zip
City State Zip
11063, 10006, 10009 0109, 0306, 0887
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Harry Lee
Name
Phone: Office # Mobile #
4040 Havelock St
Current Mailing Address
Current Street Address
Fayetteville NC 28306
City State Zip
City State Zip
Deed Book No. 3454 Page No. 39
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Deed Book No. Page No.
Provide a copy of the most current deed.