NCC223281_FRO Submitted_20220919

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 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 unavailable, place N/A in the blank.)
Part A.
1. Project Name Six Runs Stream and Wetland Mitigation Project
2. Location of land -disturbing activity: County Sampson City or Township Faison
E Darden Rd 35.096223-78.229693
Highway/Street _ LatltUde(decimaldegrees) Long ltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence: September 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Mitigation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 29.2
6. Amount of fee enclosed: $ 3000 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Daniel Burnette E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Daniel C. Evans
Name Phone: Office # Mobile #
3406 E Darden Rd
Current Mailing Address Current Street Address
Faison, NC 28341
City State Zip City State Zip
10. Deed Book No. 1919 Page No. 208 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Resource Environmental Solutions, LLC [e-mail]
Company Name E-mail Address
3600 Glenwood Ave, Suite 100 3600 Glenwood Ave, Suite 100
Current Mailing Address
Raleigh, NC 27612
Current Street Address
Raleigh, NC 27612
City State Zip City State Zip
Phone: Office # Mobile # [phone]
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 conduct the 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:
Corporation Service Company
Name of Registered Agent
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Raleigh NC 27608
[e-mail]
E-mail Address
2626 Glenwood Avenue, Suite 550
Current Street Address
Raleigh NC 27608
City State Zip City State Zip
Phone: Office # 1-800-927-9801, x62323 Mobile #
Laura Weigle
Name of Individual to Contact (if Registered Agent is a company)
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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. (This form must be signed by the Financially Responsible Person if an individuals)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Jennifer Hatchett General Manager
Type or print name
Qs�'4'1 L
Signat _r
Title or Authority
Date
I, r i5 { , a Notary Public of the County of —Q
State of North Carolina, hereby certify that A v)A&L appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of SP��� �r , 202_
GHIIISTOPHEFI A. SANTELLE N ary
Natary Pupl+larth Carmine
Wake 4ounty M commission expires ,- IA
My Commission Expires Y P
November fly, 2024

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Daniel C. Evans
Name
Phone:
Office # Mobile #
3406 E Darden Rd
Current Mailing Address
Current Street Address
Faison, NC 28341
City State
Zip City
State Zip
Deed Book No. 2056
Page No. 854
Provide a copy of the most current deed.
Landowner 3 of Record:
Daniel C. Evans
Name
Phone:
Office # Mobile #
3406 E Darden Rd
Current Mailing Address
Current Street Address
Faison, NC 28341
City State
Zip City
State Zip
Deed Book No. 21 06
Page No. 861
Provide a copy of the most current deed.
Landowner 4 of Record:
Daniel C. Evans
Name
Phone:
Office # Mobile #
3406 E Darden Rd
Current Mailing Address
Current Street Address
Faison, NC 28341
City State
Zip City
State Zip
1402
140
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Daniel C. Evans
Name
Phone:
Office # Mobile #
3406 E Darden Rd
Current Mailing Address
Current Street Address
Faison, NC 28341
City State
Zip City
State Zip
1839
325
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 6 of Record:
Daniel C. Evans
Name
Phone: Office # Mobile #
3406 E Darden Rd
Current Mailing Address
Current Street Address
Faison, NC 28341
City State
Zip City State Zip
1882
462
Deed Book No.
Page No. Provide a copy of the most current deed.
Landowner 7 of Record:
Marshall H. and Joan B.
Troublefield
Name
Phone: Office # Mobile #
8261 Faison Hwy
Current Mailing Address
Current Street Address
Faison, NC 28341
City State
Zip City State Zip
1558
297
Deed Book No.
Page No. Provide a copy of the most current deed.
Landowner 8 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.
Landowner 9 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.