NCC230895_FRO Submitted_20230420

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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Bayline Phase 3
2. Location of land-disturbing activity: County Brunswick County City or Township
Highway/Street Old Georgetown Rd _Latitude 33d54'21" Longitude 78d31'57"
3. Approximate date land-disturbing activity will commence: 07/20/2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 29.1 acres
6 Amount of fee enclosed: $ 3,000 The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No_ X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Larry Gordon E-mail Address LGordonO.criteriaconstruction.com
Telephone Cell# 347-680-7150 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Thomasboro Landco, LLC 251-850-5188
Name Telephone Fax Number
11118 US 31 Same
Current Mailing Address Current Street Address
_Spanish Fort AL 36527 Same
City State Zip City State Zip
10. Deed Book No. 4648 Page No. 1178-1194 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Thomasboro LandCo. LLC Paul( criteriadevelopment.com
Name E-mail Address
_11118 US 31
Current Mailing Address Current Street Address
Spanish Fort AL 36527 Same
City State Zip City State Zip
Telephone_251-850-5188 Fax Number

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:
Cogency Global Karenacogencvglobal.com
Name E-mail Address
212 S. Tryon St. Ste 1000 212 S. Tryon St. Ste 1000
Current Mailing Address Current Street Address
Charlotte. NC 28281 _Charlotte, NC 28281
City State Zip City State Zip
Telephone [phone] 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.
17 1y
.,,,r, U.t-tr Monate(
Type or print name Title or Authority
Sig re Date
I, n0t t45 1 l(Co , a Notary Public of the County of
State of North Carolina, hereby certify that 1,11('n on U I-I--C appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
i i )
Witness my hand and notarial seal, this � J day of J It t I - , 20 r'
(T-na- a 1
- - - -- ----- -- Notary /)
1 . (
Marty l icon Deas My commission expires OS 0 �- I -O 5
Notary Public,Alabama State at Large