NCC231177_FRO Submitted_20230518

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. Project Name Sands at Bay Line
2. Location of land-disturbing activity: County Brunswick City or Township Calabash
Highway/Street Old Georgetown Latitude(decimal degrees)39.9033 Longitude(decimal degrees)78.5392
3. Approximate date land-disturbing activity will commence: 1/5/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 24.95
6. Amount of fee enclosed: $2500 . 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 Les Basnight E-mail Address [e-mail]
Phone: Office# 251 -850-5188 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Thomasboro Landco, LLC 251-517-1606
Name Phone: Office# Mobile#
11118 US Hwy 31
Current Mailing Address Current Street Address
Spanish Fort, AL 36527
City State Zip City State Zip
10. Deed Book No. Page No. 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).
Thomasboro Landco LLC [e-mail]
Company Name E-mail Address
11118 US 31 11118 US 31
Current Mailing Address Current Street Address
Spanish Fort, AL 36527 Same
City State Zip City State Zip
Phone: Office# 251 -850-5188 Mobile#
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:
Karen McKeown [e-mail]
Name of Registered Agent 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
Phone: Office# 866-621 -3524 Mobile#
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:
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 ity to execute instruments for the Financially Responsible Party). I agree to provide
c rrected nformation should there be any change in the information provided herein.
4(1t,/ 1/0-e r )Q lr
Tyre or print name Title or Authority
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Signature Date
I, mar-- A• (DQ,cLO . a Notary Public of the County of
ALX
State of Nearall+ae hereby certify that V(1 ut. (, 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_ oPc 0 day of (Y1C_rl^.) , 20
4 41 • ic.520.43
Marty Allison Deas Notary 0
Notary Public,Alabama State at Large
My commission expires O 0)O I 5