NCC231545_FRO Submitted_20230522

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 and/
or fax information unavailable, place N/A in the blank.)
P1.art AProject Name SRI THREE - RV PARK & CAMPGROUND PHASE II
2. Location of land-disturbing activity: County CLEVELAND City or Township BOILING SPRINGS
Highway/Street OFF 150 TOWARDS GAFFNEY,SC Latitude 35.1981 Longitude-8 1 '6628
3. Approximate date land-disturbing activity will commence: Upon approval
4. Purpose of development(residential, commercial, industrial, institutional, etc.):RECREATIONAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.67 AC
6. Amount of fee enclosed: $700 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name SCOTT ROACH E-mail Address [e-mail]
Telephone [phone] Cell# 828-289-6047 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
SRI THREE, LLC 704-477-1405 N/A
Name Telephone Fax Number
PO BOX 1600 225 BRENT HALL CT
Current Mailing Address Current Street Address
MATTHEWS NC 28106 CHARLOTTE NC 28270
City State Zip City State Zip
10. Deed Book No. 1830 Page No.593-595 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
SRI THREE, LLC [e-mail]
Name E-mail Address
PO BOX 1600 225 BRENT HALL CT
Current Mailing Address Current Street Address
MATTHEWS NC 28106 CHARLOTTE NC 28270
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
George Joseph Selembo Jr. [e-mail]
Name of Registered Agent E-mail Address
PO BOX 1600 225 BRENT HALL CT
Current Mailing Address Current Street Address
CHARLOTTE NC 28106 CHARLOTTE NC 28270
City State Zip City State Zip
Telephone [phone] 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.
George Joseph Selembo Jr. PRESIDENT
Ty.,- or print name Title or Authority
- � fir +- 17- 0-
Signature Date
I, . .. SGo-FvAe-* , a Notary Public of the County of Z111Efe--a_P
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that/the above form was
executed by him. r-�V
Witness my hand and notarial seal, this I l''day of 1 V , 20
B Scott Roach
NOTARY PUBLIC __
Rutherford County, NC Nota
My Commissio6E0ires June 08,2026 71 �-4L
My commission expires tykf ,, )- 124*