NCC223789_FRO Submitted_20221118

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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_ Eastern Pines Dental
2. Location of land -disturbing activity: County -raven City or Township New Bern
Highway/Street Waterscape Way Latitude(decimai degrees) 35.03111 Longitude(decimal degrees) 77.010556
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.3 Acres
6. Amount of fee enclosed $700 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed X No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott T. Anderson
Phone: Office # 252-565-1015
E-mail Address scoff@arkconsultinrayour�.com
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
EPD Properties, LLC 252-944-3918
I YOI I IG
PO Box 467
Current Mailing Address
Chocowinity NC
City State
10. Deed Book No. 3738
Phone: Office #
518 Poore Farm Rd.
252-944-5255
Mobile #
Current Street Address
27817 Chocowinity NC 27817
Zip City State Zip
Page No. 1132 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).
EPD Properties, LLC
Company Name
P.O. Box 467
Current Mailing Address
Chocowinity NC 27817
City State Zip
Phone: Office # 252-944-3918
[e-mail]
E-mail Address
518 Poore Farm Rd.
Current Street Address
Chocowinity NC
City State
Mobile # [phone]
27817
M
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
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State
Zip
(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 #
State
E-mail Address
Current Street Address
Zip City State Zip
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Ark Consulting Group, PLLC
Engineering firm or other consultant
Scott T. Anderson, PE
Individual contact person (type or print)
scoff arkconsultin grouF.com
E-mail Address
252-565-1015 252-258-0734
Phone: Office # Mobile #
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.
Pamela Beavers Ward
Type or print name
iot- - a z, L 0(
Signature
I
Scott T. Anderson_
Managing Member
Title or Authority
D 09 2-0�
Date
, a Notary Public of the County of
Pitt
State of North Carolina, hereby certify that Pamela Beavers Ward 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 23rd day of August , 20 22
114ti'ilE! ,
eaIO fi R Y = My commission expires November 26, 2023
-- cn \;
r7' coo,

Continued from Items 9 & 90 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:
Name
Current Mailing Address
City
Deed Book No.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
Current Mailing Address
City State
Deed Book No. _
Landowner 4 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
City State
Deed Book No.
State Zip
Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Zip City
Page No. Provide a
Phone: Office #
Mobile #
State Zip
copy of the most current deed.
Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 1 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.
Company 2 Name
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State
Mobile #
Zip
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile # _ _