NCC221919_FRO Submitted_20220527

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 Qualityr Submit the comp�eted form to the appropriate
Regional Office. (Please type or print and, if the question is not applicabJe or the e-mail address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Spring Meadows Subdivision
2 Location of land -disturbing activity� County Moore City or Township Pinebluff
HighwaylStreet Spring Meadows Dr Latitude�d�imal degrees) 35,12511 Lori gitude� decimal di�grees 1 -7947541
3 Approximate date land -disturbing activity will commence5/1/22
4. Purpose of development (residential, commercial, industrial, institutional, etc ):Residential
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas), 53
6 Amount of fee enclosed: S 5,300 . The application fee of $100 00 per acre (rounded
up to the next acre) is assessed without a ceilfng 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 No
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity.
Name Braden Riley E-mail Address brad en (_W ri I eyan dwal ker. com
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Riley & Walker Development, LLC 919-601 -1217
Name Phone: Office # Mobile #
PO Box 3248 20 Birkdale Way
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
city State Zip City State Zip
10. Deed Book No 5630 Page No 207-210 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 company is a soleproprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible pafty(ies),
Riley & Walker Development, LLC [e-mail]
Company Name E-mail Address
PO Box 3248 20 Birkdale Way
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NG 28374
City State Zip City State
Phone: Office # Mobile# [phone]
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 iand disturbing activity.
2 (a) If the Financially Responsible Party is a domestic company reg�stered on the NC Secretary of State
business registry, 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
Phone. Office # 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 DSA 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.
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Type or print name
Signature
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Title or Authority
4
Date
L All uO."MM-A a Notary Public of the County of 9:A'�&-Rr
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the abovJ form was executed by him/her.
Witness my hand and notarial seal, this L
J___day of 2012Q
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MY commission expires_9 - 1 —4 - a-e,
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