NCC216242_FRO Submitted_20211109

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Environment and Natural Resources. (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.
1. Project Name Magnolia Hill Parcel 4
2. Location of land -disturbing activity: County Moore City or Township Carthage
Highway/Street: NC Hwy.22 Latitude 35.2643 Longitude-79.4140
3. Approximate date land -disturbing activity will commence: October, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Future Commerical
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7
6. Amount of fee enclosed: $2,205.00 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
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 James B. O'Malley E-mail Address iomalley()omalleydevelopment.com
Telephone Cell # 414-573-0855 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Tyler's Ridge Business Park, LLC 414-573-0855
Name Telephone
121 National Drive
Current Mailing Address
Pinehurst NC 28374
City
State Zip
121 National Drive
Current Street Address
Pinehurst NC
City
Fax Number
28374
State Zip
10. Deed Book 5674 Page No. 501 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Tyler's Ridge Business Park, LLC Iomalley(a)omalleydevelopment.com
Name E-mail Address
121 National Drive
121 National Drive
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State
Telephone [phone]
Zip City State Zip
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:
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
LKC Engineering, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
Philip Picerno 910-420-1437
Individual contact person (type or print) 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.
James B. O'Malley Member
Ty or print name Title or Authority
`3D N10/18/21
ignat re Date
1, f;Z:j ? -t1 �,t , a Notary Public of the County of Alcor <_
State of North Carolina, hereby certify that J cu-yie S 15 d'N1G- ( I Cy appeared personally
before me this } � vfftsduly sworn acknowledged that the above form was exe uted by him.
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Witness mjAAd_aC{'riq?§iaAVA, this iCt day of � t��G� , 20' 1
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s AV9L1G s Notary
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