NCC222370_FRO Submitted_20220708

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 NIA in the blank.)
Part A.
Project Name: Evolve Holly Ridge RV Phase 2
2. Location of land -disturbing activity: County: Onslow City or Township: Holly Ridge
Highway/Street E Ocean Road_ Latitude: 34° 29' 08" N Longitude: 770 33' 16"W
3. Approximate date land -disturbing activity will commence: July 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.0_
6. Amount of fee enclosed: $ 585 The application fee of $65.00 per acre (rounded up to the next acre)
is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No: Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mike Winstead E-mail Address: mike _evolvecos.com
Telephone: [phone] Fax #: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
A & T Enterprises C/O Sandra Thompson
Name Telephone
7812 Saint Annes Way Same as Mailing Address
Current Mailing Address Current Street Address
Fuguay Varina NC 27526
City State Zip City
State
10. Deed Book No. 1208 Page No. 80 Provide a copy of the most current deed.
Part B.
Fax Number
Zip
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):
Evolve RV Holly Ridge. LLC [phone]
Name Telephone Fax Number
2918-A Martinsville Road Same as Mailing Address
Current Mailing Address Current Street Address
Greensboro NC 27408
City State Zip City 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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
Parry is a Corporation, give name and street address of the Registered Agent:
Name of Manager E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone: Fax Number:
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 infXn
hhould there be any change in the information provided herein.
Mike WJ r Manager
Type or print Title or Authority
Signature Date
a Notary Public of the County of NCo nzd o aeP
State of North Carolina, hereby certify that l� G��uta 1✓ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. .!
Witness my hand and notarial seal, this c2 day of 20� �
ACOQaeprrpjh
ZZu
vi
Seal z
My commission expires
�y,'T,QA; ., n,,,„s••OJ�`�Q .y� r "
,,'Ofe..OVE Ga.N ',F-.1