NCC223518_FRO Submitted_20221013

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 NIA in the blank.)
Part A.
1. Project Name White Oak Shores -- Driveway Relocation
2.
Location of land -disturbing activity: County Carteret City or Township Ste I Ia
452 wetherington Landing Road 344622.28" N 771
S'1 i.25"W
Highway/Street Latitude{decimal degrees) LongltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: 1 0/1 5/2022
4. Purpose of development (residential, commercial, industrial, institutional, ,,.):Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.94 ae
6. Amount of fee enclosed: $ 900.00 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 0 Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Austin Greenhalge E-mail [e-mail]
Phone: Office # [phone] Mobile # [phone]
43
Landowner(s) of Record (attach accompanied page to list additional owners):
MHC White Oak Shores, L.P. (312) 279--1880 [phone]
Name Phone: Office # Mobile #
Two N. Riverside Plaza Suite 800 Two N. Riverside Plaza Suite 800
Current Mailing Address Current Street Address
Chicago IL, 60606 Chicago IL, 60606
City State Zip City State Zip
10. Deed Book No. 1 685 Page No. 234 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 names) of the owner(s) may be listed as the financially responsible party(ies)_
MHC White Oak Shores, L.P.
Company Name
Two N. Riverside Plaza Suite 800
Current Mailing Address
Chicago IL, 60606
City State Zip
Phone: Office# [phone]
george, [e-mail]
E-mail Address
Two N. Riverside Plaza Suite 800
Current Street Address
Chicago IL, 60606
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:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
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:
CT Corporation System george_gudgeoni)equitylifestyle.com
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh, NC 27615
City
State
Current Street Address
_ Raleigh, NC 27615
Zip City State Zip
Phone: Office # (312) 279- 1880 Mobile # [phone]
George Gudgeon
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 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 7shild there be any change in information provided ein.
Type or ri Title or Authority
Signature Date
1, i it l f) (� , a ]votary Public of the County of 60DIC
State of Iona, hereby certify that i/1i frGr i 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, thi day of� 20�
Sea: I
OFF1 AL SEAL.
MARIA Gi EZ
NILLINOIS
OTARY
comet s5 ON EXPIRES.0105/225
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My commission expires "