NCC223821_FRO Submitted_20221115

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 NameCool Run Stream and Wetland Mitigation Site
2. Location of land -disturbing activity: County Brunswick City or TownshipShallotte
Highway/Street
Starboard Rd. NW _ Latltude(decimaldegrees) 33.970904Long ltUde(decimaldegrees) -78.472509
3. Approximate date land -disturbing activity will commence: October 15, 2022
Stream and Wetland Restoration
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):24.57
6. Amount of fee enclosed: $2 , 500.00 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.
Has an erosion and sediment control plan been filed? Yes 0 Enclosed ❑ No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Yates E-mail Address [e-mail]
Phone: Office # 91 9-624-6901 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Pearl D. Frink 843-241-8902
Name Phone: Office # Mobile #
1758 Frink Street SW 1758 Frink Street SW
Current Mailing Address Current Street Address
Ocean Isle Beach NC 28669 Ocean Isle Beach NC 28669
City State Zip City State Zip
10. Deed Book No.3348 Page No. 1120 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).
Clearwater Mitigation Solutions, LLC
Company Name
604 Macon Place
[e-mail]
E-mail Address
604 Macon Place
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
City State Zip City State Zip
Phone: Office # 91 9-624-6901 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:
Clearwater Mitigation Solutions, LLC
Name of Registered Agent
604 Macon Place
Current Mailing Address
Raleigh, NC 27609
[e-mail]
E-mail Address
604 Macon Place
Current Street Address
Raleigh, NC 27609
City State Zip City State Zip
Phone: Office # 91 9-624-6901 Mobile # [phone]
Kevin Yates
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)

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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
state Zip City 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,
Kevin Yates Principal 1 Owner
Type or print name Title or Authority
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Sign re pate
1, ";" L�j wt , a Notary Public of the County of v.LR
State of North Carolina, hereby certify that _-1421L tus, �,�c r _ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this? -Li day of A 207-Z
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2� Notary
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My commission expires
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