NCC215706_FRO Submitted_20211019

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. 150 Backhoe Road 3
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Leland
Highway/Street Backhoe Rd NE Latitude 34 13' 01 "N Longitude 78 01' 45"W
3. Approximate date land -disturbing activity will commence: upon receipt of permit
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.95
6. Amount of fee enclosed: $ 520 . 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Burt Moody E-mail Address bm @tcllnc.com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
JBS Associates, LLC
910-523-1981 910-371-0929
Name
Telephone Fax Number
150-A Backhoe Road
NE 150-A Backhoe Road NE
Current Mailing Address
Current Street Address
Leland, NC 28451
Leland, NC 28451
City State
Zip City State Zip
10. Deed Book No. 1050/1 124
Page No. 0125/0884 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.
JBS Associates, LLC
[e-mail]
Name
E-mail Address
150-A Backhoe Road NE 150-A Backhoe Road NW
Current Mailing Address
Current Street Address
Leland, NC 28451
Leland, NC 28451
City
State Zip
City
State
Zip
Telephone [phone] Fax Number 910-371-0929

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:
NA
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:
NA
Name of Registered Agent
Current Mailing Address
City
State Zip
E-mail Address
Current Street Address
City
Telephone Fax Number.
State Zip
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.
Burt Moody Member Manager
Type or print name
,,-Signature
--------------------------------------------------------------
Title or Authority
Date
� m /J
I, �/i�iA� 13•. zt _10,r/'l a Notary Public of the County of illP
State of North Carolina, hereby certify that A IdD appeared
personally before me this day and being duly sworn acknowlecvged that the above form was
executed by him.
nnEh.a ` day of �C� �
Witness+r
��`�n�ar��tyrial seal this 20 a �
NoTaRy1<aaw
tary
My commission expires
��/ioQVER iG�O�������