NCC232551_FRO Submitted_20230829

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more aonan 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 Geotiun, N.C. Department of Environmental Quality. Submit the completed form tothe
appropriate Regional Office. (Please hype or print and, if the question im not applicable or the e-mail and/
or fax information unavailable, place N/A in the b|ank.)
Part A. �������hJ� ������
1. Project Name
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2. Location ofland-disturbing activity: County~~`"~~"-~~", City or Township
��(���|� 1 ��� �/1��R_O� A7 _��_��_O� ��
Hi�h�ay/Gtpesd '"`^`~^ ^ ' `"-~' LedKudm~'' '° ``"'^^' Longitude ' ^ ~-~ °`''^-^-
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3. Approximate date land-disturbing activity vviUuonnmenne:'"��NOV EMBER^ '' °-"°- '
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4. Purpose of development(nesidenUe[ oonnmanoio|. induatho|. inndtuUona|. a�.}:^ ^~-~�`^�^-`" ' " ^^-
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5. Total acreage disturbed or uncovered (indudingmf-e�ebornmvand waste anaaa): ='~^
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G. Annountof fee enclosed: *"-"=��'""RR
The application fee of$G5.UO per acre (rounded
upto the next acre)in assessed without e ceiling amount (Exomp|e: a9-eore application fee io$585).
7. Has an erosion and sediment control plan been filed? Yaa^~��
No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
���k��J | |�|��X��~�� �6��w��N|��� co[�
Nen�a���" ^'" L. PIERCE^~��- E-mail [e-mail]
��1R_���;q-���M �1M-�/1�-1�1A
Telephone ~~-`~" °~^^^^~ Cell Far# � '= ~-`~ '~- `=
8. Landowner(s)of Record (attach accompanied page to list additional owners):
0^�f��[�'���� |��f6��tn[� Inc. �18� ��1��-���QM /�1O\ �&�-1�1O
Diversified,- ^ °^ ^ . �^^ .=� `~_,° ^~~~°° `� .~� ~ .~ . ..
Nome Telephone Fax Number
P'O.Box 1685 405 Johnson Blvd.
Current Mailing Address Current Street Address
Jacksonville NC 28541 Jacksonville NC 28540
city State Zip City State Zip
10. Deed Book No.=�-`'����� Page No.��^ ==��
Provide a copy of the most current deed.
PartB.
1. Comnpany(iea) or Unn(m) who are financially responsible for the land-disturbing activity (Provide o
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proplietorship,
the name of the owner or manager may be listed as the financially responsible party.
Diversified |O\/estmFs Inc. beftwF`@j|ODc'c000 `
Name E-mail Address
P_O,Box 1685 405 Johnson Blvd.
Current Mailing Address Current Street Address
Jacksonville NC 28541 Jacksonville NC 28540
City State Zip City State Zip
���1�� ���_��OR /C�1�\ ��1A-1�1�
Telephone ^^-�° °~'�= FsmNumb�r\� '"/ �-,^^ '°- '°

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:
Name E-mail Address
Current Mailing Address Current Street Address
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:
Betty Bullock [e-mail]
Name of Registered Agent E-mail Address
P.O. Box 1685 405 Johnson Blvd.
Current Mailing Address Current Street Address
Jacksonville NC 28541 Jacksonville NC 28540
City State Zip City State Zip
Telephone[phone] Fax Number(910) 346-1210
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.
Betty Bullock President
Type print name Title or Authority
ic/i
Signatu e Date
4-10.111Avo. MCID0MN.to , a Notary Public of the County of orrb LA)
State of North Carolina, hereby certify that 15e±1+A tA appeared
personally before me this day and being duly swoacknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this k s day of eiCk-Obe.)- , 20 7-
(-01
otary
H• MCDONALD
'ARY PUBLIC My commission expires A1151./S-t 2025
— Onslow County
North Carolina
My Commission Expires August 17,2025