NCC233299_FRO Submitted_20231103

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Tidal Wave Auto Spa - Goldsboro
*If this project involves American Rescue Plan Act(ARPA) funds. list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: CountyWayne City or Township Goldsboro
1027 N Spence Ave 35.3880 -77.9479
Highway/Street Latitude degrees) LongltUde(decimal degrees)
3. Approximate date land-disturbing activity will commence:9/29/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .13
6. Amount of fee enclosed: $200 . 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 El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameJohn Wells E-mail [e-mail]
Phone: Office# 706-647-0414 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
SHJ Development LLC 706-647-0414
Name Phone: Office# Mobile#
115 E Thompson Street 115 E Thompson Street
Current Mailing Address Current Street Address
Thomaston, GA 30286 Thomaston, GA 30286
City State Zip City State Zip
Page No.3832
10. Deed Book No.503 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).
SHJ Development LLC [e-mail]
Company Name E-mail Address
124 E Thompson Street 124 E Thompson Street
Current Mailing Address Current Street Address
Thomaston, GA 30286 Thomaston, GA 30286
City State Zip City State Zip
Phone: Office#706-647-0414 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:
First American Title Insurance Company [e-mail]
Name of Registered Agent E-mail Address
223 S West Street, Suite 900 223 S West Street, Suite 900
Current Mailing Address Current Street Address
Raleigh, NC 27603 Raleigh, NC 27603
City State Zip City State Zip
Phone: Office# 402-697-4667 Mobile#
Luke Maher
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.
TlbAL 14-501-v4-A---ro S;,a
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.
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Type or pri► % Title or Authority
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/tfr/i..0 Signat re Date
I, Ur; r'rNe Nk.ni 6L , a Notary Public of the County of 0p.,0 r,
State of+46444Cariza, hereby certify that Amax,44.e Y u r Thy appeared personally
before me this day and being duly sworn acknowledged that the above fora was executed by him/her.
Witness my hand and notarial seal, this 1 g day of ()C,AI i/3 Q (' , 20 a3
otary
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