NCC222343_FRO Submitted_20220707

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 Atlantic RV Resort (CARTE-2022-023)
2. Location of land -disturbing activity: County Carteret City or Township Atlantic
Highway/Street Morris Marina Rd. Latitude(decimai degrees) 34.8962 Longitude(decimai degrees)-76.3233
3. Approximate date land -disturbing activity will commence: Violation
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Future RV Park
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12 acres
6. Amount of fee enclosed: $ 1,200.00 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Chadwick E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Coresounders of Atlantic, LLC 252-725-0820
Name
688 Highway 70 Otway
Phone: Office #
Current Mailing Address Current Street Address
Beaufort NC 28516
Mobile #
City State Zip City State Zip
10. Deed Book No. 1752 & 1753 Page No. 046 & 391 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 sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Coresounders of Atlantic, LLC
Company Name
688 Highway 70 Otway
Current Mailing Address
Beaufort NC 28516
City State Zip
Phone: Office #
[e-mail]
E-mail Address
Current Street Address
City State Zip
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 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:
Melissa Berryman [e-mail]
Name of Registered Agent E-mail Address
710 Arendell St., Suite 105
Current Mailing Address Current Street Address
Morehead City NC 28557
City State Zip City State Zip
Phone: Office # [phone] 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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
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.
Chris Chadwick
Type or me
Signature
Manager, Coresounders of Atlantic, LLC
Title or Authority
Date
I, VMVW CQX a Notary Public of the County of C 0 Y l-eyP.�
State of North Carolina, hereby certify that Q Y 1s OM6w\(A' appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal,
F 03yF�
O'f A R y 54
— —' Seal —
:C'
this 5 day of MOLU, 20 T1
j
kla U-) 2. 22
Notary
My commission expires 1\IW com

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:
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 3 of Record:
Mobile #
State Zip
Provide a copy of the most current deed.
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 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.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed
to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #