NCC223236_FRO Submitted_20220915

11
FINANCIAL RESPONSIBIL"IOWNERSHIP 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 bean 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 and/
or fax Information unavailable, place NIA in the blank.)
Part A. Brazda Commercial Rentals
1. Project Name
2. Location of land -disturbing activity: CountyCarteret City or Township Newport
HighwaylStreet Hwy L4 Latitude 34043'36.33"N Longitude 76°55'17.01 "W
3. Approximate date land -disturbing activity will commence:0812022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commereial
S. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.55 acres
6. Amount of fee enclosed: $ 400 . 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:
Name Josh Johnson E-mail [e-mail]
Telephone [phone] Celt # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Brazda Commercial Rentals (252)-646-3142
Name Telephone Fax Number
2645 Hwy 24 same
Current Mailing Address Current Street Address
Newport, NC 28570
City State Zip City state ZIP
10. Deed Book No. 1 735 Page No. 231 Provide a copy of the most current deed.
Part 13.
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 sore proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Brazda Marine Inc. [e-mail]
Name E-mail Address
2645 Hwy 24 same
Current Mailing Address Current Street Address
Newport, NC 28570
r
City State Zip
Telephone [phone]
City State �P
Fax Numt)cr

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'.
ame
Current Mailing Address
State ZIP
Telephone
E-mail Address
Current Street Address
Ciry 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
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.
Frank Brazda
Type or nt n me
Sig ur�ey/,
owner/Manager
Title or Authority
Date
l ( v S �} ( sY a Notary Public of the County of s
State of North Carolina, hereby certify that --a-AA�
a�)4 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
witness my hand, an n0tartat deal, this da;Otaryv
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