NCC221928_FRO Submitted_20220526

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 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 N/A in the blank.)
Part A.
1,
2.
3.
4.
5.
6.
7.
Project Name Rocky Run Road Shops
Location of land -disturbing activity: County Onslow
Highway/Street 2509 Piney Green Rd Latitude 34'43'41 "N
City or Township White Oak
Longitude 77019'14"W
Approximate date land -disturbing activity will commence: June 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2•6
Amount of fee enclosed: $195.00 The application fee of $65.00 per acre (rounded
up to the next acne) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Christopher W. Bailey E-mail [e-mail]
Telephone [phone] __ Cell # _ _ _ _ Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Trade Land Company, LLC [phone]
Name Telephone Fax Number
P.O. Box 3435
Current Mailing Address
Greenville, NC 27836
City State
10. Deed Book No. 4235
Part B.
426 W. Longmeadows Rd.
Current Street Address
Greenville,NC 27858
Zip City State Zip
Page No. 859 Provide a copy of the most current deed.
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):
Bailey and Associates, Inc. [e-mail]
Name E-mail Address
P.O. Box 400
Current Mailing Address
Jacksonville, NC 28541
�antv State
405-D Western Blvd.
Current Street Address
Jacksonville, NC 28546
Zip City
Telephone [phone] Fax Number
State
—Zip

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
City
Telephone
state Zip
Current Street Address
City
Fax Number
State Zip
(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
E-mail Address
Current Street Address
City State Zip City
Telephone 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.
Chri her W. Bailey
T or tint a
;igrI ature
President
Title or Authority
4-5--2,U2Z
Date
a Notary Public of the County of IDLA)
State of North Carolina, hereby certify that Christopher W. Bailey appeared
personally before' me this day and being duly swom acknowledged that the above form was
executed by
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Witness an nd no sat, this day of ApLTL , 2t) 2
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C4 2022.FORMS.ROCWRUNROAO.FINRESPONS.032922