NCC222481_FRO Submitted_20220711

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 andt
or fax information unavailable, place N/A in the blank.)
Part A. Smith Road Property Subdivision
1. Project Name p y
2. Location of land -disturbing activity: County Cumberland City or Township Grays Creek
Highway/Street Smith Road Latitude34.937325 Longitude-78.862611
3. Approximate date land -disturbing activity will commence: March 20, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.5
6. Amount of fee enclosed: $ 1,500 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. 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:
NameTim Evans [e-mail]
Telephone [phone] cell # 910-273-5016 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gallberry Run Land and Development, LLC 910-273-5016
10
Name Telephone
4239 Cameron Road
Current Mailing Address
Fayetteville NC 28306
City State Zip
Deed Book No. 11241 Page No. 21
Current Street Address
City
Fax Number
State
Zip
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Gallberry Run Land and Development, LLC [e-mail]
Name E-mail Address
4239 Cameron Road
Current Mailing Address Current Street Address
Fayetteville NC 28306
City State Zip City
Telephone [phone]
Fax Number
State
WE

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 Current Street Address
City State Zip City State Zip
Telephone 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
Party is a Corporation, 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
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 information should there be any change in the information provided herein.
Tim Evans
or name
Signature
President
Title or Authority
Date
a Notary Public of the County of C yy'c 111r!C�
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn a d nowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of v 20
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