NCC222494_FRO Submitted_20220719

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.
Project Name SOUTHPORT CROSSINGS
2. Location of land -disturbing activity: County BRUNSWICK City or Township Southport
Highway/Street Hwy 211 and Hwy 133 Latitude 33057'15.53"N Longitude 78' 3'3.51 "W
3. Approximate date land -disturbing activity will commence: August 2016
4. Purpose of development (residential, commercial, industrial, institutional; etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 47 Acres
6. Amount of fee enclosed: $ 3,055.00 . The application fee of $65.00 per acre (rounded up
to the next acre) is assessed without a ceiling amount. (Example: 9 acres total is $585).
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
Name Richard E. Rowe E-mail Address rerwakefld(o)-aol.com
Telephone [phone] Cell [phone] Fax [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MDI Management, LLC [phone] [phone]
Name Telephone Fax Number
120 Fourth St. 120 Fourth St.
Current Mailing Address Current Street Address
Hickory INC 28602 Hickory NC 28602
City State Zip City State Zip
10. Deed Book No. 3569 Page No. 246 Provide a copy of the most current deed.
Part B.
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):
Wakefield Associates [phone] [phone]
Name Telephone Fax Number
Same 188 Wind Chime Court, Suite 201
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number [phone]

2. (a) If the Financially Responsible Party is not a resident of Noftr Carolina give nalYna and street address
of the designated North Carolina Agent:
m
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
Party is a Corporation, give name and street add ess of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
hard E. Rowe
ype r print name
Sig'nature
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President
Title or Authority
Date
I, a Notary Public of the County of
State of North Carolina, hereby certify that _�_� - 'C_O, 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 _�D'O` day of 20 ) (e,
_ c Z
Kathryn R. Young Nblary
N,%ary Public
Seaburham County �Z/Z�
orth Carolina My cor�jimission expires
M CommiNo
ire s 1 2018