NCC223144_FRO Submitted_20220908

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No.person may initiateany 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 address or phone
number is unavalable, place N/A in the blank.)
Part A.
1. Project Name471.5 & 4715A Trent River Road Land Disturbance
2. Location of land -disturbing activity: County Graven City or Township Trent Woods
Highway/StreetTreTif River Road Latitude{d©amald9gma4 761 Longitudetd�maldegcaesi77.fotsa9
3. Approximate date land -disturbing activity will commence: July 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, efc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):1' 59
6. Amount of fee enclosed: $200.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre- application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George Zayfioun, Jr.
Phone: Office # 252.633.0106
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):,
Georg_ a Zaytoun, Jr. 252,633.0106 252.671.3388
Name Phone: Office # Mobile #
128 Trent Shores Dr
Current Mailing Address Current Street Address
New Bern NC 28562
City
State Zip
New Bern NC 28562
City State Zip
10. Deed Book No. 3721 Page No. 0425 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible. parties on accompanied page.) If the company is a sole proprietorship or ifthe landowner(s) is
an indivldual(s), the name(s) o'the owner(s) maybe listed as the iinanclolly responslble paIfAles).
GrepZwc 7ZA-(-toutA 7q�- ,Ato G---6a4A.rcoViS}ru cjc� • ceh
teams IisC;'1V1DV-k- NABrE E-mail Address
IZ G TiL�Cr 4N(oZ3 . '06JT
Current Mailing Address Current Street Address
ti� F V1 NL ZZ- t�Ic—�1S \L Z`3'5.Z.
City State Zip City State Zip
Phone: Office # Z�Z_ 63� olb6 Mobile
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to cpnductthe anticipated land disturbing activity.
2..(a) if the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent,
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
city state Zip City
Phone: Office #.
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) if the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State zip
Phone: Office #
E-mall Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party Is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (Thisform must be signed by the Financially Responsible Person if an individual(s)
or his dttorney-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 Party). i agree to provide
corrected information should there be any change in the information provided herein.
George Zaytoun, Jr
T rint name
Signature
Owner
Title or Authority
Date
1, vy f r)' dch _ a Notary Public of the County Of
State of North Carolina, hereby certify that ��iUn jY, appeared personally
before me this day and being duly sworn ocknowledg that the Above form i(ias executed by him/her-
Witness my hand and notarial seal, this day of.200a
�+���,pnnrepnjrr i
:• •. '� Notary
My commission expires t1

Continued from Barns 9 & io in Part A of the Financial Responsibility/ownership Form for multiple
owners. Attachcopies of this page as needed .to list all landowners.
Landowner 2 of Record:
K(252) 256-1449
Kelly Zaytoun
Name Phone: -Office.# Mobile #
2113 Hidden Harbor Drive 2113 Hidden Harbor Drive
Current Mailing Address Current`Street Address
New Bern NC 28562 New Bern NC
28562
City State Zip City State Zip
Deed Book N0 3721 Page No. 0619 Provide a copy of the most current deed.
Landowner 3,of Record:
Name
Phone: Office # Mobile #
Current Mailing Address Current Street Address
State Lip
City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner4 of Record:
Name. Phone: Office #1 Mobile #
Current Mailing Address Current Street Address
City State Zip City
State
EIId
Deed Book No, Page No. Provide a copy of the most current. deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip city State zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 7 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of #his page as needed to list alf financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office#
Company 3 Name
Mobile #
E-mail Address
Current Mailing Address Current Street.Address
City State_ Zip City State Zip
Phone: Office
Mobile #
Company 4 Name E-mail Address
Current Mailing Address
Current Street, Address
City State Zip City State Zip
Phone: Office # Mobile
Company 5 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office #. Mobile #