NCC221730_FRO Submitted_20220505

FINANCIAL RESPONSIBILITYIOWNERSHIP 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: Calabash Marina
! Li - r r nu ud +..�.L.ing tivil.r. !'�..un'r 1r.........'..1. r •'+ . T ... l.' lr l L lw
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Highway/Street Riverview Dr Latitude (decimal degrees) _33.886$* ongitude(dedmal degrees)-78.5633l
3. Approximate date land -disturbing activity will commence: 4/14/2022
It.
Purpose ofuCYGlVtJl ilGiil,nt I�gltlGli Lida, 4Vll lliiCr4I k %J LIE41, IIIJLiLU LiO.Ial, ec'.):—colllmerciali
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): —3,30
6. Amount of fee enclosed: $_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).
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7_ Has an erosion and sediment control plan been filed? Yes ® Enclosed ❑ No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Natme: ile. TI: I i R A0or 1.
• E-mail Address: tmoon@calabashmarina,com
+ Phone: Office # 910-579-6440
• Phone Mobile # [phone]
g i anrintivner(c) of Record (afiiarn arr0mnaniar7 nano to lici ar{riitioriai Ownerci'
• Name: Southern Marinas Calabash LP.
• Office Phone: [phone]
• Cell: Manager & Site Contact - Tim Moon - 239-288-9621
• Mailina and Current_ Address-
• 6671 W Indiantown Road. Suite 50 453
• Jupiter, Florida. 33458
10. Deed Book No and Page NO. See enclosed deed.
Provide a copy of the most current deed. See enclosed Deed.

Part B.
1. f'mmnanvfiecl whn are finanriailv rpfinnne hla for the land -dish jrhinn nn ivity (PrnViria a rntr�nreh,7rlcivr lice
ra.. y _r _
__....3 i r. _
Of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the names) of the owner(s) may be listed as the financially responsible party(ies).
Cam an Name: Southern Marinas Calabash LP
E-mail Address: info Acalabashmarina.com;
VUIIIWIIL Mai IIIIU Add GSS OL C­UIfGI1L Street Add I Cs.7.
6671 W Indiantown Road. Suite 50 453.
Jupiter, Florida. 33458
Phone: Office # 561-412-4941
Mobile # Tim Moon Site Manager & Manager: 239-288-9621
Note: If the Financially Responsible Parry is not the owner of the land to be disturbed, include with this form
the landowners 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) It 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:
Sosld : 2329828
Name of Registered Agent Corporate Service Companies
C i.111 C11t IYICIf sill Address & VLif1C11L Stree
t Address:
2626 Glenwood Avenue Suite 550
Raleigh, North Carolina. 27608
Email: N/A Filing done online.
Phone: Head Office # 866-403-5272
Name of Individual to Contact (if Registered Agent is a comoanv): NIA
(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 -fait, or if not an individual, ay an officer, director, partner, or re�jisiered agent wlih
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.
Gary R smarin
Typ or prin e
Signature
Authorized Person
ritle or Authority
April 28, 2022
Date
-h o 14 �rITL , a Notary Public of the County of Pa !
FSoart8A
State of North eefe4ma, hereby certify that r 0 r f _ _appeared personally
before me this day and being duly sworn acknowled d that the above form was executed by him/her.
Witness my hand and notarial seal, this g o day ofI L , 20 2-022
2a�►�;;ie�n KR(sTINAGRITz Notary
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