NCC232912_FRO Submitted_20231018

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 Environment and Natural Resources. (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.
1. Project Name Mill Creek
2. Location of land-disturbing activity: County Pitt City or Township_Greenville
Highway/Street 900 Finn Ct Latitude 35.565 Longitude -77.436
3. Approximate date land-disturbing activity will commence:__8/30/2023
4. Purpose of development (residential, commercial, industrial, institutional,
etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_29
6. Amount of fee enclosed: $_65 . The application fee of$65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bonita Spain E-mail Address bonitabspainaol.com
Telephone [phone] Cell# [phone] Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Spain Builders, LLP [phone] [phone]
Name Telephone Fax Number
609-D Country Club Dr 609-D Country Club Dr
Current Mailing Address Current Street Address
Greenville. NC 27834 Greenville NC 27834
City State Zip City State Zip
10. Deed Book No._90 Page No._47 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
5 a �3�;��� ,�°� bonitaspain aC aol.com
Name E-mail Address
609-D Country Club Dr 609-D Country Club Dr ..
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville - NC = 27834
City State Zip City . State Zip

Telephone [phone] Fax Number [phone]
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
'V-\ G f, 3 nal n Ownpr
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Sign Date
I, 10 \\ k( ,,(\ , a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my ha�nl,a d„ /-�
gotarial seal, this �` day of v..9,A S'�" , 20 2.4
���,r`to\C‘e SPai�
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Notary
My commission expires i2 6 2.02-
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