NCC242193_FRO Submitted_20240724

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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
[2uaUb/ Section, N.C. Department ofEnvironmental Quality. Submit the completed form to the appropriate
Regional Office. (Please b/pm or print and, if the question is not applicable or the e-mail address or phone
number im unavailable, place N/A in the b|ank.)
Part A.
Serenity Crossing
1. Pn�e�Nmme= '^� = ' ~
2. Location of land-disturbing activity: County OOs|gw City orTownship White Oak
����O0��� ����� ��� ��� '774483
Highway/Street ~ Road La�hmdew^u=uo�nmo>~ ~� ~ LonOdud�mmaw�o���) '
U�6�
3. Approximate date land-disturbing activity viU oommence: ~] ' ~-��~~ 'M�&
4' Purpose of development(residential,commercial,industrial, institutional, etc.); Residential
5. Total acreage disturbed nr uncovered (including of-oit u1�
eborn��andmmuhmoramo)� ~~~M
G. Amount of fee anok �1
enclosed: '`8�~�M^~~M�
. The application fee of$1UD.D0 per acre(rounded
upto the next acre)io assessed without a ceiling amount (Exomp!e: 8.10'eona application fee|a$gOV).
Checks should be addressed hoNCDEQ.
7. Has on erosion and sediment control plan been filed? Yes[I Enclosed 0 No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
]��� ��'���� 6�#V���V��� co0D
Nomne~ '' ^ ' E�mei|Addro�a ~[e-mail]
�1M-��#-����Q ��1D-����-OM1�
Phone� O�om# ~ `~ ~ '~ ~~~_ ��b|ks# � ' ~ _~~ ~- '~
8. Landowner(s)of Record(attach accompanied page to list additional owners):
ByeaVer Creek Investors, Inc. 910-346-9800 910~389-0015
Name Phone OfOma# Mobile#
P,O, Box 1685 405 Johnson Blvd
Current Mailing Address Current Street Address
Jacksonville NC 28451 Jacksonville NC 28450
C]8y State Zip City State Zip
���^1 ���-����
10. DamdBonkNo.~~^~ ' Page No.~-' ~ ~-' � Provide o copy of the most current deed.

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Part B.
1. Compony(iee)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties onaccompanied bholanohwmer(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(les).
Beaver Creek Investor, Inc. [e-mail]0
Company Name E-mail Address
P,O, Box 1685 405 ]OhDsQn Blvd
Current Mailing Address Current Street Address
JacksQM\/'UB NC 28451 Jacksonville NC 28450
CRY State Zip City State Zip
�in-�&��-����lM �1��-����-M�1�
Phone: OfDce# � '~ ~ '~ ~~~~~ K4obUo# ~ '~ ~^'~ ~~ '~
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 Gbehe Zip
Phone: Offioe# K8ob||o#
Name of Individual to Contact(if Registered Agent|smcompany)
(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:
Nome cf Registered Agent E-mail Address
Current Mailing Address Current Street Address
city State Zip City State Zip
Phone: Of5ca# yNobi|a#
Name nf Individual ho Contact(if Registered Agent ioacompany)

(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.
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.
Betty Bullock President of Beaver Creek Investors, Inc.
Type or print name Title or Authority
ifhtfazdie 1Z/. 9/2-5,
sign
at0 Date
I, Oicole 171i'a eye - , a Notary Public of the County of 011slot..)
State of North Carolina,hereby certify that-ZeAk‘i'Z(Aliodc 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 29 day of Apr)) , 20 2.41
•;* .........$;*'e, Notary
\AUTA6)1.. My commission expires 0 )0 Li 1.202M
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