NCC230722_FRO Submitted_20230321

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
2
3
Project Name Oyster Creek Landing
Location of land -disturbing activity: County Pender City or Township Hampstead
Highway/Street Latitude
(decimal y Hwy 17/Hoover Road ( decimal degrees) 34.370681 Longltude(decimal degrees) 77.708308
Approximate date land -disturbing activity will commence: 11 /14/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.0
6. Amount of fee enclosed: $ 600.00 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 p No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mr. Louis Dworsky E-mail Address [e-mail]
Phone: Office # [phone]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hampstead Station, LLC [phone]
Name
PO Box 11634
Current Mailing Address
Charlotte, NC 28220
City State
10. Deed Book No. 4787
Phone: Office # Mobile #
903 Long Cove Drive
Current Street Address
Wilmington, NC 28405
Zip City
Page No. 2908-2913
State
Zip
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).
Hampstead Station, LLC
Company Name
PO Box 11634
Current Mailing Address
Charlotte, NC 28220
City State Zip
Phone: office # [phone]
[e-mail]
E-mail Address
903 Long Cove Drive
Current Street Address
Wilmington, NC 28405
City State
Mobile # [phone]
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:
Louis Dworsky
Name of Registered Agent
PO Box 11634
Current Mailing Address
Charlotte, NC 28220
1-ILy
Idd12486Qa gmail.com
E-mail Address
903 Long Cove Drive
Current Street Address
Wilmington, NC 28405
State Zip City
Phone: Office # [phone] Mobile # [phone]
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 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)

(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 exe uments for the Financially Responsible Party). I agree to provide
corrected inforSat6n should t re be any change in the information provided herein.
Louis D)mlo rsky f Member
Type or,4rint name
Title or Authority
1n-6-22.
Date
a Notary Public of the County of w--
State of North Carolina, hereby certify that UVILS. 1W O "S?L.— 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 day of dC-�) (at-- , 20 a�
Notary
My commission expires
ALMrW SSTHAL
Notary Public
New Hanover County, North Carolina
My Commission Explres April 22, 2t)23

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.
Double Dimension, LLC [phone] [phone]
Name Phone: Office # Mobile #
2324 Pansy Street, SW 2324 Pansy Street, SW
Current Mailing Address
Huntsville, AL 35801
Current Street Address
Huntsville, AL 35801
City State Zip City State Zip
Deed Book No. 4792 Page No.1246-1249 provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No..
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office #
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
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.
NOT APPLICABLE
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
City
Phone: Office #
Company 5 Name
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
E-mail Address
Current Street Address
State Zip City State
Mobile #
State
Zip
Zip