NCC242056_FRO Submitted_20240723

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Custom Home Distribution Center
2. Location of land-disturbing activity: County_Brunswick_City or Township_Leland
Highway/Street_2100 Enterprise Drive_Latitude(decimal degrees)_34.2622 Longitude(decimal degrees)_78.0723_
3. Approximate date land-disturbing activity will commence:_February, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_7.25
6. Amount of fee enclosed: $ $800 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name_John Cockrum/Environments Unlimited_ E-mail [e-mail]
Phone: Office#_910-399-6717 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_John Gray/2100 Enterprise Holdings, LLC _910-799-4010 _910-620-6316
Name Phone: Office# Mobile#
_3514 South College Road 3514 South College Drive
Current Mailing Address Current Street Address
_Wilmington NC _28412 _Wilmington, NC 28412
City State Zip City State Zip
10. Deed Book No._4897_Page No._484_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).
_2100 Enterprise Holdings, LLC [e-mail]
Company Name E-mail Address
_3514 South College Road _3514 South College Road
Current Mailing Address Current Street Address
Wilmington NC_ 28412 Wilmington NC 28412_
City State Zip City State Zip
Phone: Office#_910-799-4010 Mobile# [phone]
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:
_John Gray [e-mail]
Name of Registered Agent E-mail Address
_3514 South College Road 3514 South College Road
Current Mailing Address Current Street Address
Wilmington NC_28412 Wilmington NC_ 28412
City State Zip City State Zip
Phone: Office#_910-799-4010 Mobile# [phone]
_John Gray
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:
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)

(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.
N/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.
_John Gray Registered Agent
Type or grin Title or Authority
8/
Signat e Date
I, l nc. a wQ\Q.C. , a Notary Public of the County of e:)RuoSU i'e4,
State of North Carolina, hereby certify that d Oh n G C4.\( appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this !J day of—Deoembei , 20 p `
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