NCC232272_FRO Submitted_20230804

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may inrtrate any Land-disturbing actrvity 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 Ouality Section, N C Department of Environment and Natural Resources. (Please type or pant and, if
tl)c question is not applrcable or the e-marl and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Protect Name The Bluffs at Sloon Pint
2. Location of land-disturbing actrvity- County Pendef City or Township Hampstead
HighwaytStreet SR 1563 Latitude 349 4' 14"N Longitude_77'37' Z5"W
3. Approximate date land-disturbing activity will commence. 09101/2072
4. Purpose of development(residential,aannmercial, industrial, institutional, etc. ) R idential
5. FctaI acreage disturbed or uncovered (including off-site borrow and waste areas)- old 5
6. Arn❑unt of fee encAo sCd- $ Z925 _` The appoccat*n feu of $65.00 per acre {rounded up
to the next acre)is assA�,%F.ed without a Ceding amount {Fxample a 9 acre application fue is 5585)
7 Has an efosran and sediment control plan been hied? Yes X No Enclosed X
8 Person to contact should erosion and Sediment Control issues arse during land-disturbing activity
Name Oan-y S. Parr. P F L-mail Address_gpa pp@gsp consultant .corn
Telephone [phone] _- Cetl# Fax# 910-/9"659
9 t andowner(s)of Record (attach accompanied page to list additional owners).
Signature Top Sail N__C_ l.xd 713-872 1
Narne Telephone Fax Number
93378 Katy Freeway#377
Current Mailing Address Current Street Addisss
�oton TX T 024
City State Tip City State Zip
10 Deed Book No. 4775 Page No. 18I4 Provide;a copy of the most current dived.
Part B_
1 Person(s) or firm(s) who are financially responsible for the Land-disturbing aCtivrty r'Pruvide a
comprehensive list of all responsible parties on an attached street):
.5�n.*ur-e Top bull NC, Ltd. _ mikeQs+anature-comoanw.s.r.❑m
Name - - - E-mail Address
6450 Shinnwood Road
Current Mailing Address Currant Street Address
Wilmnaton NC 28409
City `titate Zip City State Zip
I elephone 713-$?a, 8g1 Fax Number

2 (a)It the FvsancaaDyr Responsate Party is not a nmwoenr cd riorh C.arrfira gr+ra nwne aad street it+dd't>sf
of 0*dpsrgnawd North Carolina A9n;
Name s=4rwiii Address
Curren MamV Add, Currant SIreet Adore=
Ctry State 7.,p C+ry Stave Zip
Telep One _.. Fax fvsxrtza--
(b) It ft Fw► m:asyr Rcsportsibbe Party is a Ponrier-ahip or ottxx pers4ri engaging in business ur►Gef ar•
matmad narnr. mach a comer of the Corby to of Assulfted N&m- if the r-wQr+ce ly Responsible
Cor-
,C,aton."name aid sweet address of MC Registered Agent:
�[3' H -P1 rrk rtihl'r�f �7n �
Nix. of R[g. i%ered Agent £-rrrai Addresr.
545Q!fit+MM!gQq RCI;K_ --
Currcrl MAng Addr(--:, Curren! Stream ACdrLs.;
YAimingW NC__
Crty State ZIP City Mate 7jp
7etepmxw 7 Fax Number
The above rnformabon m tsu+ and correr—* to the best of my ledge and miief arwd was provided
by me under oats (This town MmV be signed by ti-e Fir►andWty Res+pombi- Person rt an indiv9 at
or his a(tor-A-yir�tdot or if not an individwf. by an officer. diredor, panner, or r egi'slerW agent with
,+e auittorsty to execute insburnerx.: for the F-nanoafly Rcsponscb;e Person). 1 nme to provide
created ffykarmabw should there be arty change in&W inform3bon prowled herein
Allachael H_Po3�_ic_ - _. man�g�s
TypMe or pn Trtie or r4jM wty
Signati m Date
i ___aar. 5 P.py_ a Notwy Pvbk of the County off N i tanq±Mr
State of North Caroina rweby cer&y aiat ,. MM2Wi K P 'Izk appeared pe—s( Vy before
me L'r+s day aM being tuty sworn acknowledged lt+at the above form was exetxfed try hkr
AMr+ess my hard and nctanS seal.tits ► �day of 20
)CV, My r:trss:�axaires_Agr+iA5