NCC223239_FRO Submitted_20220921

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 Camden Preserve - Phase 2
2. Location of land -disturbing activity: County Cumberland City or Township Hope Mills
Camden Road 34.973259-78.997968
Highway/Street LatltUde(decimal degrees) Long ltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: 10/01/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.00
6. Amount of fee enclosed: $ PREVIOUSLY PAID 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 ❑
0
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mr. David Bloom E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Barbara M. Johnson, Heirs [phone]
Name Phone: Office #
PO Box 53349 1007 Hay Street
Current Mailing Address
Fayetteville, NC 28305
City State
10. Deed Book No. 2856
Mobile #
Current Street Address
Fayetteville, NC 28305
Zip City State Zip
Page No. 539 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 if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
GFB Associates III, LLC
Company Name
537 Market Street, Suite 400
Current Mailing Address
Chattanooga, TN 37402
City State Zip
Phone: Office # 423 752-0188
[e-mail]
E-mail Address
537 Market Street, Suite 400
Current Street Address
Chattanooga, TN 37402
City State Zip
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:
Rebecca F. Person
Name of Registered Agent
231 Fairway Drive
Current Mailing Address
Fayetteville, NC 28305
City
State Zip
Phone: Office # (910) 491-422
[e-mail]
E-mail Address
Current Street Address
City State Zip
Fax (g 10) 491-2476
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
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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 individual(s)
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.
Fox Johnston
Type or print na
Member
Title or Authority
Date
-----------------------------------
I, ' 1 rz t anvx- a Notary Public of the County of atqrvq" 1 4j
State of h jQW
om, hereby certify that F—cv� �bknsk-OtJ appeared personally
before me this day and being duly sworn acknowl de ged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of `)--eO-kno ke i , 20 � -
g�Ptu�r�i
'.:�Q',•;i`ip���'""" Notary
�F
TEN sSEE My commission expires
I

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.
NOT APPLICABLE
Landowner 2 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 3 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
City
Deed Book No._
Landowner 4 of Record:
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Mobile #
State Zip
Provide a copy of the most current deed.
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 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 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
NOT APPLICABLE
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name 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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip