NCC240545_FRO Submitted_20240226

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 I bL Kel S N;+e_
2. Location of land-disturbing activity: County roe-5yi-le\- City or Township ar frier sville
Highway/Street t-Vetme Plaza tr. Latitude SC0.Og0, Longitude — TO. 0c04 5
3. Approximate date land-disturbing activity will commence: K ( i 1 2-y
4. Purpose of development(residential, commercial, industrial, institutional, etc.) C_ow►wLe-ru m I
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 02.9 0
6. Amount of fee enclosed: $ 300 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 Enclosed r/
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name $o.k ( E-mail Address SaIN(()p e-o let osf corn
I
Telephone 6111- Z7q - CnCo 3 3 Cell# Fax#
9 Landowner(s) of Record (attach accompanied page to list additional owners)
Opal DevCo I, LLC
Name - Telephone Fax Number
3 ZI 0 F4.;r1,.;l 1 :r;vc_ SiA- ( Od
Current Mailing Address Current Street Address
NC_ 2.74212
City State Zip City State Zip
10. Deed Book No. 31 21 Page No. NS 3 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Opal DevCo I, LLC Caul sa �oa�Ino�el5)ro��• corn
Narhe E-mail Address
3 Z 1� �0�✓1.,'�l l IOC
Current Mailing Address Current Street Address
27‘12.-
City State Zip City State Zip
Telephone 11`i - 7 -$I`{a 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:
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:
p_0.v `Avi , eke_5ai (d ,p oal�o�t�sgreLT prv.
Name of Registered Agent E-mail Address �� oral
�J
321 o Fa;c l-t;l l J�r:ve_ 51.42 00
Current Mailing Address Current Street Address
`Gi�L. &)L Z7(o(Z
City State Zip City State Zip
Telephone 9 (9 - `/-/7— 81 N O 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.
Rav /i(owt el
Type or print n me Title or Authorit`
iiiii2-q
Signatur Date
I. MI6 r\ 11\ot 5 'Pc i* 1 , a Notary Public of the County of '�
State of North Carolina, hereby certify that QCI.V 1 SJ e A appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. I I
oin
Witness my hand and notarial seal, this day of ,�anu,GUr 20 `i MUO\Kid,--\
MONIKAS PATEL Notary
1 Notary Pubjicforth Carolina
Wait0gdunty p '^� 5
My Commission Expires Jun 16, 2025 i My commission expires J t�/in 1 1 1 aU

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
0Pa..1 CAS►i-4,41 ZGL (-av 6i,...2_5a; e„LI l,A.o1-.4Sjrovp• Gorvx.
Company 2 Name E-mail Address
3210 Fa+r! L.:() iThe, u14-. _ 100
Current Mailing Address Current Street Address
Z0.1L;q1^, N C- 2?(c1Z-
City J State Zip City State Zip
Phone: Office# `r~/ t - 777- Sig 0 Mobile#
P A7co SP6. V a(r u_c, , 5,5,,k, 1 e ,...i. v l 0 5P, _,:i-•, . c 0✓+1
Company 3 Name E-mail Address 1
3210 ru;rt•; It .bfi'v2. 5i..;1-.._ MO
Current Mailing Address Current Street eztle-ii tr. 1.1 C_ 27(v 12
City State Zip City State Zip
Phone: Office# i 4, - 7? - g t 10 Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#