NCC242375_FRO Submitted_20240813

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. Banner Ridge Subdivision - Phase One
1. Project Name
2. Location of land-disturbing activity: County Johnston City o Township Banner
Highway/Street Surles Road Latitude 35.3591 Longitude -78.5280
3. Approximate date land-disturbing activity will commence: Upon receipt of permit.
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 35.22
6. Amount of fee enclosed: $ 3,600.00 . 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 X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lanny Clifton E-mail Address [e-mail]
Telephone (919) 971 - 5353 Cell # (919) 971 - 5353 Fax# (919) 934 - 3100
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Surles Road Land Development, L.L.C. (919) 971 - 5353 (919) 934 - 3100
Name Telephone Fax Number
5160 NC Highway 42 West 5160 NC Highway 42 West
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
10. Deed Book No. 06365 Page No. 0168 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.
Surles Road Land Development, L.L.C. [e-mail]
Name E-mail Address
5160 NC Highway 42 West 5160 NC Highway 42 West
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
Telephone (919) 971 - 5353 Fax Number (919) 934 - 3100

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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.
Lanny Clifton Member Manager
Type or pri name Title or Authority
,4/9/24
ure Date
I, 1/It`'1, U ►(Yltlr �� a Notary Public of the County of �UrA,'15 ►' 1
•
State of North arolina, hereby certify that L n Li _�� � 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 ( day of LA 3rI , 20-llll --
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