NCC232344_FRO Submitted_20230824

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
Emmitt's Crossing
1. Project Name
Cumberland Fayetteville
2. Location of land-disturbing activity. County City or Township
Cliffdale Rd 35 028589 -79.061599
Highway/Street Latitude(decimai degrees, Long itude(decimal degrees)
03/01/2023
3 Approximate date land-disturbing activity will commence:
Commercial
4. Purpose of development (residential, commercial, industrial. institutional, etc.):
4.14
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas)
$1,750
6. Amount of fee enclosed . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is$250 per acre up to eight acres. after which the Express
Permitting supplemental fee is a fixed$2.000.00 (Example: 8.10-acre application fee is$2.900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity.
Jake Lambson [e-mail]
Name E-mail Address
801-669-7824
Phone: Office# Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Harold J. Kidd 910-237-9228 910-237-9228
Name Phone Office# Mobile#
6885 Cliffdale Rd 6885 Cliffdale Rd
Current Mailing Address Current Street Address
Fayetteville, NC 28314 Fayetteville. NC 28314
City State Zip City State Zip
7650 0435-0437
10. Deed Book No Page No. Provide a copy of the most current deed.

Part B.
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).
Surge Development [e-mail]
Company Name E-mail Address
1875 South State Street Suite#1400 1875 South State Street
Current Mailing Address Current Street Address
Orem, Ut, 84097 Orem, UT, 84097
City State Zip City State Zip
801-669-7824
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
business registry, 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
Phone: Office# Mobile#
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:
ECS Southeast, LLP [e-mail]
Name of Registered Agent E-mail Address
5260 Greens Dairy Road 5260 Greens Dairy Road
Current Mailing Address Current Street Address
Raleigh, Fayetteville, NC 28304
City State Zip City State Zip
919-861-9910 919-291-9200
Phone: Office# Mobile#
Shannon Priester
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

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Johnny H. Boyles 910-709-0407 910-709-0407
Name Phone: Office# Mobile#
289 West Palmer Street 289 West Palmer Street
Current Mailing Address Current Street Address
Raeford, NC 28376 Raeford, NC 28376
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Joseph H. Gillis 910-309-2001 910-309-2001
Name Phone: Office# Mobile#
8623 Galatia Church Road 8623 Galatia Church Road
Current Mailing Address Current Street Address
Fayetteville, NC 28303 Fayetteville, NC 28303
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Apex Engineering, INC. [e-mail]
Engineering firm or other consultant E-mail Address
Eric Hatfield 801-796-2277
Individual contact person (type or print) Phone. Office# Mobile#
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.
Jake Lambson Entitlement Specialist
Type or print name Title or Authority
1/1 11/03/2022
Signature 71 Date
I, ����- �• . a Notary Public of the County of
State of , ereby certify thatc1-6014. LiLanibrivn aka.Ja..ktj appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this d y of N - , 20 22-
NOTARY PUBLIC
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