NCC222611_FRO Submitted_20220725

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.
1. Project Name John's Auto Sales
2. Location of land -disturbing activity: County Brunswick City or Township Lockwood Folly Township
Highway/Street 2667 Ocean Hwy Latitude 33 deg - 59' - 14" N Longitude -78 deg - 21' - 27" W
US HWY 17
3. Approximate date land -disturbing activity will commence: September 1, 2022
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10
Purpose of development (residential, commercial, industrial, institutional, etc.): t,ar aaies uoi
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.5 ac
Amount of fee enclosed: $ 300.00 . 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).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Sullivan E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
John's Auto Sales, Inc. 910-754-4740
Name Telephone Fax Number
711 Tatum Road SW 711 Tatum Road SW
Current Mailing Address Current Street Address
Shallote, NC 28470 Shallote, NC 28470
City State Zip City State Zip
Deed Book No. 03723 Page No. 0581 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):
John's Auto Sales, Inc. [e-mail]
Name
711 Tatum Road SW
Current Mailing Address
Shallote, NC 28470
City State Zip
Telephone [phone]
E-mail Address
711 Tatum Road SW
Current Street Address
Shallote, NC 28470
City State Zip
Fax Number

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
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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.
John Sullivan
Type or print name
President
Title or Authority
__gdA r Ja4pr� v-zz
Sig ature Date
a Notary Public of the County of r�,�,.ic� rc /C
State of North Carolina, hereby certify that -To -�5c� t by 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 I t7)h day of J atY , 20 2 Z-
JONATHAN S SULLIVAN
f iOTAPY PUPLIC
BRUN;'WiIlrC'K COUNTY, NC
MY Commis , P)!
N ota
My commission expires u- 3" - 2 G