NCC230002_FRO Submitted_20230104

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 Cedar Point Crossing
2. Location of land -disturbing activity. County Carteret City or Township Cedar Point
Highway/Street Old NC-58 Latitude(,i imaiae9ree5) 34.689 Longitude(deeimaldegrees)-77.073
8. Approximate date land -disturbing activity will commence: Januar 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.35 ac.
6. Amount of fee enclosed: $ 1,500.00 . 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matthew Hill E-mail Address [e-mail]
Phone: Office # 252-946-5175 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wal-Mart Stores East, LP 888-724-9870 NIA
Name Phone: Office # Mobile #
160 Mine Lake Court - Ste 200 160 Mine Lake Court - Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
10. Deed Book No. 1222 Page No. 169 , 171 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.) !f 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).
CP Development Company, LLC
Company Name
[e-mail]
E-mail Address
3920 Magazine Street 3920 Magazine Street
Current Mailing Address T Current Street Address
New Orleans LA 70115-2641 New Orleans
City State Zip City
Phone: Office # 504=866-7300 Mobile # NIP,
LA 70115-2641
State
.Zip
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:
NIA
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State ,Zip
Phone: Office # Mobile #
N/A
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:
Capitol Corporate Services, Inc. [e-mail]
Name of Registered Agent E-mail Address
176 Mine Lake Court - Ste 100 176 Mine Lake Court - Ste 100
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: office # 888-844-8360 Mobile # NIA
Yvette Cleveland, Assistant Secretary on behalf of Capitol Corporate Services, Inc.
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.
NIA
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 heroin.
Gordon H. Kolb, Jr.
Type or print name
Signature
Wisset _SC-k,n,Jler
Manager
Title or Authority
iO1zY(z'Oy"
Date
a Notary Public of the County of -SOC f5 a+n
L- O LA I.51 A IV ac
State of Ne4h-esra"a, hereby certify that &OV80n 4 Klb, -`r. 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 c�27 't� day of 20c)A_
Sertl
Notary
My commission expires_
N[)7r;RY PUBLIC
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