NCC233795_FRO Submitted_20240110

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Bo ue Sound RV Resort
1. Project Name g _
2. Location of land-disturbing activity: County Carteret City or Township Cedar Point
Highway/Street 1204 Cedar Point Blvd Latitude 34°68'38.60"N Longitude 77°06'96.41"W
3. Approximate date land-disturbing activity will commence:Fall 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 0.98 AC
6. Amount of fee enclosed: $ 100.00 . 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? Yes No X Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ashton Smith E-mail Address [e-mail]
Telephone[phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Bogue Sound RV Owner, LLC [phone]
Name Telephone Fax Number
555 Mission Street, Suite 3300 555 Mission Street, Suite 3300
Current Mailing Address Current Street Address
San Francisco CA 94105 San Francisco CA 94105
City State Zip City State Zip
10. Deed Book No. 1767 Page No. 109 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Bogue Sound RV Owner, LLC [e-mail]
Name E-mail Address
555 Mission Street, Suite 3300 555 Mission Street, Suite 3300
Current Mailing Address Current Street Address
San Francisco CA 94105 San Francisco CA 94105
City State Zip City State Zip
Telephone[phone] Fax Number

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:
CT Corporation System
Name E-mail Address
160 Mine Lake Ct, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417
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.
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Type or print Title or Authority
Signat Date
I �i.A.&24 (4ty [ C''✓ 0` a Notary Public of the Germ of '06 Y CA O e—C-o
, hereby certify that j M VJ ki (I eCE .u..I appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this -4- day of 20 23
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