NCC222919_FRO Submitted_20220902

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.
1. Project Name Bayline North Phase 2
2. Location of land -disturbing activity: County Brunswick County City or Township
Highway/Street Thomasboro Rd Sw _Latitude 33.5440 Longitude_-78.3120
3. Approximate date land -disturbing activity will commence: 06/20/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 46.7 acres
6. Amount of fee enclosed: $ 4,700 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No_ _X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Larry Gordon E-mail Address LGordon([e-mail]
Telephone Cell # 347-680-7150 Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Thomasboro Landco, LLC 251-850-5188
Name Telephone Fax Number
11118 US 31 Same
Current Mailing Address Current Street Address
_Spanish Fort AL 36527 Same
City State Zip City State Zip
10. Deed Book No. 4648 Page No
Part B.
1178-1194
Provide a copy of the most current deed.
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):
Thomasboro LandCo, LLC Pau [e-mail] _
Name E-mail Address
_11118 US 31
Current Mailing Address
Spanish Fort AL 36527
City State Zip
Current Street Address
Same
City
State
Zip
Telephone_251-850-5188 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:
Cogency Global
Name
212 S. Trvon St, Ste 1000
Current Mailing Address
Charlotte. NC 28281
City State Zip
Telephone [phone]
Karen( a�coaencvalobal com
E-mail Address
212 S. Trvon St, Ste 1000
Current Street Address
_ Charlotte, NC 28281
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 Zip
Telephone
E-mail Address
Current Street Address
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.
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Type,, o print name
Sign
Title or Auth Pori
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Date .
1. cmdu W'6 , a Notary Public of the County of _ iOjbiyy i 1^
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State of hereby certify that Marl im U *t"( 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 �: today of 1-)JW 20 .Z
Notary
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ENotaryPubllc,
llison Deas /
labama State at Large My commission expires