NCC230500_FRO Submitted_20230307

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 NameSurf City, NC - Petco
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land -disturbing activity: County Pender City or Township Surf City
NC HWY 210 34.45-77.565278
Highway/Street Latitude{decimal degrees) Long ltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: 04.01.2022
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
6. Amount of fee enclosed: $ 200.00 . 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 [91 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Gabriel Martinez E-mail Address [e-mail]
Phone: Office # 512.819.4767 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
PC -SURF CITY, NC-1-UT, LLC 512.819.4767
Name
4747 Williams Drive
Phone: Office # Mobile #
4747 Williams Drive
Current Mailing Address Current Street Address
Georgetown, TX 78633 Georgetown, TX 78633
City State Zip City State Zip
10. Deed Book No. 4792 Page No. 2639-2641 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).
PC -Surf City, NC-1-UT, LLC
Company Name
4747 Williams Drive
Current Mailing Address
Georgetown, TX 78633
City
[e-mail]
E-mail Address
4747 Williams Drive
Current Street Address
Georgetown, TX 78633
State Zip city
State
Phone: Office# 512.819.4767 Mobile# [phone]
0
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:
Cogency Global, Inc.
Name of Registered Agent
212 South Tryon Street, Suite 1000
Current Mailing Address
Charlotte, NC 28281 -0001
City
[e-mail]
E-mail Address
212 South Tryon Street, Suite 1000
Current Street Address
State Zip city
State Zip
Phone: Office# 866.775.0114 Mobile# [phone] - Fax #
Colleen Humes
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:
Cogency Global, Inc.
Name of Registered Agent
212 South Tryon Street, Suite 1000
Current Mailing Address
Charlotte, NC 28281 -0001
City
State Zip
Phone: Office# 866.775.0114
Colleen Humes
E-mail Address
212 South Tryon Street, Suite 1000
Current Street Address
Charlotte, NC 28281 -0001
City State Zip
Mobile# [phone] - Fax #
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.
N/A
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.
Tommy Waters Vice President - Real Estate
Type or print name PC -surf city, NC-1-UT LLC Title or Authority
By mbr a Development Group, Inc. Member
I - 3- 2v-2_3
Signature Date
------------------------------------------------------------------------------------------------------------------------------------
I, EmVv k, NAL4vil Z- -,a Notary Public of the County of IAJI U ,W.01I
State of iiwa, hereby certify that -RVhM Q WA'u'Ks 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 y�day of 16kht'20',7 '6
EMMA L. MUNIZ Notary
.ap•' �y Notary Public, State of Taxes
5 `"Comm. Expires 08-17-2026
�'�;O y�, Notary ro 13382013-2 My commission expires

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.
Landowner 2 of Record:
N/A
N/A
N/A
Name
Phone:
Office# Mobile #
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip city
State Zip
Deed Book No. N/A
Page No. N/A
Provide a copy of the most current deed.
Landowner 3 of Record:
N/A
N/A
N/A
Name
Phone:
Office# Mobile #
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip City
State Zip
Deed Book No. N/A
Page No. N/A
Provide a copy of the most current deed.
Landowner 4 of Record:
N/A
N/A
N/A
Name
Phone:
Office# Mobile #
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip City
State Zip
Deed Book No. N/A
Page No. N/A
Provide a copy of the most current deed.
Landowner 5 of Record:
N/A
N/A
N/A
Name
N/A
Current Mailing Address
N/A
City State
Deed Book No. N/A
Phone: Office#
N/A
Current Street Address
N/A
Mobile #
Zip City State Zip
Page No. N/A Provide a copy of the most current deed.

Continued from Item I in Part B of the Financial ResponsibilitylOwnership Form for multiple parties.
Attach copies of this page as needed to list al/ financially responsible parties.
N/A N/A
Company 2 Name
N/A
Current Mailing Address
N/A
City State
Phone: Office# N/A
N/A
Company 3 Name
N/A
Current Mailing Address
N/A
City State
Phone: Office# N/A
N/A
Company 4 Name
N/A
Current Mailing Address
N/A
City State
Phone: Office# N/A
N/A
Company 5 Name
N/A
Current Mailing Address
N/A
City State
Phone: Office# N/A
E-mail Address
N/A
Current Street Address
N/A
21:-P— city State Zip
Mobile # N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip city State Zip
Mobile # N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip city State
Mobile # N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
0
Zip city State Zip
Mobile# N/A