NCC231736_FRO Submitted_20230613

NT#21099
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. Stanbury Creek Subdivision
1. Project Name
2. Location of land-disturbing activity: County Brunswick City or Township Lockwood Folly
Stone Chimney Road (SR1119) 33° 56' 30" 78° 15' 10"
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence: _
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 67
6. Amount of fee enclosed: $ previously paid . 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Telephone [phone] Cell# 910-471-9638 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Stanbury Creek NC, LLC 757-463-5000
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
4598
10. Deed Book No. Page No. 657 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.
Stanbury Creek NC, LLC [e-mail]
Name E-mail Address
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
N/A
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 Ct. Ste.200
Current Mailing Address Current Street Address
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 i
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. Stanbury Creek NC, LLC, By TMPR, LLC, its Manager
By:
Raymond L. Gott • pok•4E6' 1 /p/1 Lie Manager(TMPR, LLC)
Type or print n. r- Title or Authority
I I3/aA
Signature Date
I, Cynthia G.Shank , a Notary Public of the County of Virginia Beach
VIRGINIA
State ofIRRESEESsit hereby certify that Raymond L.Gottlieb
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 3 day of .� o�i ,20 01,2
___Okjdie.. 3cSLcsJ(
Seal Notary
Cynthia G. Shank My commission expires 10/31/2024
Notary Public
REG. # 213972
Commonwealth of Virginia
MY COMMISSION EXPIRES OCTOBER 31, 2024