NCC232416_FRO Submitted_20230810

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 Queens Ridge Townhomes
2. Location of land-disturbing activity: County Onslow City or Township Hubert
Highway/Street Queens Creek Rd. Latitude(decimai degrees) 34.677446 Longitude(decimal degrees) 77'18845
3. Approximate date land-disturbing activity will commence: August 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 14.2
1 500.00
6. Amount of fee enclosed: $ 7 . 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 0 No ❑x
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Elijah Morton E-mail Address ElljahM©rnortontrucking.com
Phone: Office# 910-548-7575 Mobile# [phone]
9, Landowner(s)of Record (attach accompanied page to list additional owners):
Tokrnan Foods, Inc. 910-546-2358
Name Phone: Office# Mobile#
PO Box 35 674 West Corbett Ave.
Current Mailing Address Current Street Address
Swansboro NC 28584 Swansboro NC 28584
City State Zip City State Zip
10. Deed Book No.4620, 4876 Page No. 354, 667 Provide a copy of the most current deed.

Part S.
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).
Queens Ridge Developers, LLC ElijahM©mortontrucking.com
Company Name E-mail Address
121 Garnet Lane 121 Garnet Lane
Current Mailing Address Current Street Address
Jacksonville NC 28546 Jacksonville NC 28546
City State Zip City State Zip
910-548--7575
Phone: Office# 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
j ! business registry, give name and street address of the Registered Agent:
Elijah Morton ElijahM©mortontrucking.com
Name of Registered Agent E-mail Address
121 Garnet Lane 121 Garnet Lane
Current Mailing Address Current Street Address
Jacksonville NC 28546 Jacksonville NC 28546
City State . Zip City State Zip
Phone: Office# 910-548-7575 Mobile# [phone]
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 authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Elijah Morton Member
Typ r pr'nt nam Title or Authority
Date
( I
I, J eft ea-- reRce , a Notary Public of the County of ®nslb�
State of North Carolina, hereby certify that El‘i car-}nrt appeared personally
before me this day and being duly sworn acknowlec � (',ed that the above form was executed by him/her.
Witness my hand and notarial seal, this t3 day of , 20 a3
•
�c_�e_t Cy'�.�-U
JESSICA LAWRENCE -��
Notary Public Notary
ISM h Carolina
Onslow County My commission expires -- -off

CONSENT LETTER
Property Owner: Financially Responsible Party:
Tokman Foods, Inc. Queens Ridge Developers, LLC
674 West Corbett Ave 121 Garnet Lane
Swansboro, NC 28557 Jacksonville, NC 28546
RE: Queens Ridge Townhomes
Onslow County, NC
I To Whom It May Concern:
This letter gives Queens Ridge Developers, LLC authority to pursue plan approvals for erosion and sediment
control plans for Queens Ridge Townhomes, located on Queens Creek Road (SR 1509) near Hubert, North
Carolina. We also give permission for Queens Ridge Developers, LLC to perform construction on this property
subject to Tokman Foods, Inc. prior review and approval.
Tokman Foods, Inc.
Property Owner Name/Organization
Sammer Rahman, President
Signing Official Name & Title
O 4 /t3/23
Signature Date
I',