NCC231465_FRO Submitted_20230524

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.)
Part A. Pelican Landing
Project Name g
2. Location of land-disturbing activity: County Brunswick City or Township Leland
Highway/Street 1607 River Rd SE Latitude 34.177661 Longitude-77.991736
3. Approximate date land-disturbing activity will commence: May 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11 .41 AC
6. Amount of fee enclosed: $ 1,200 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac= $900.00).
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 Rob Herrington E-mail Address [e-mail]
Telephone [phone] Cell# 843-241-0327 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pelican Landing NC, LLC By:TMPR, LLC,its Manager
Name Telephone Fax Number
448 Viking Drive, Suite 220 448 Viking Drive, Suite 220
Current Mailing Address Current Street Address
Virginia Beach VA 23452 Virginia Beach VA 23452
City State Zip City State Zip
10. Deed Book No.0495 Page No.0918 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.
Pelican Landing NC, LLC By:TMPR, LLC,its Manager [e-mail]
Name E-mail Address
448 Viking Drive, Suite 220 448 Viking Drive, Suite 220
Current Mailing Address Current Street Address
Virginia Beach VA 23452 Virginia Beach VA 23452
City State Zip City State Zip
Telephone [phone] 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:
CT Corporation System
Name E-mail Address
160 Mine Lake Courtt, Suite 200 160 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
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:
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.
Raymond L. Gottlieb Manager - TMPR, LLC
Type or print nam Title or Authority
e2
Signature Date
Cynthia G. Shank a Notary Public of the County of Virginia Beach
VI-flint?, Raymond L. Gottlieb
State of 14e ri eli ., hereby certify that y appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this i Li day of February 2023
.(-1 �`' - (3• c1
Cynthia G. Shank Nota
N tary Public
SR . # 213972irginia 10/31/2024
MY COMMISSION EXPIRES OCTOBER 31, 2024 My commission expires

Exhibit A—Property Owners Table
Pelican Landing NC, LLC
448 Viking Drive,Suite 220
Virginia Beach,VA, 23452
Parcel ID: 05900002
PIN:3105-1047-8188
Deed Book 04876, Page 0390