NCC241207_FRO Submitted_20240418

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.)
P1. Part roject Name Wilmington Dental Office
2. Location of land-disturbing activity: County New Hanover City or Township Wilmington
Highway/Street 5413 Watergrass Drive Latitude 34.1330 Longitude-77.9201
3. Approximate date land-disturbing activity will commence:05/01/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):0.96
6. Amount of fee enclosed: $ 100 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chad Cornwell E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
WMG Acquisitions, LLC 314-803-3222
Name Telephone Fax Number
270 W. Plant Street, Suite 210
Current Mailing Address Current Street Address
Winter Garden, FL 34787
City State Zip City State Zip
10. Deed Book No.6679 Page No.2716 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.
WMG Acquisitions, LLC [e-mail]
Name E-mail Address
270 W. Plant Street, Suite 210
Current Mailing Address Current Street Address
Winter Garden, FL 34787
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:
Corporation Service Company [e-mail]
Name E-mail Address
2626 Glenwood Ave, Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number 302-636-5454
(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.
Authorized Represented Sylvia M. Buxbaum
Tye e or rint name Title or Authority
Signatit Date
I, U n(1S 1 l A I L I L , a Notary Public of the County of NeUJ Caul.€
D' 1rU 1'
State of Nert hereby certify that Si1 VI 0 M. R1,1)(h01,Ur appeared
personally before me this day and being d y sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this nth of Apr\1 , 2024.
Lindsey A. Eick ( c ',�
Notary Public Notary ►'
sgge of Delaware II /�
My Commission Expires 06-21-2025 My commission expires O[OI21 12025