NCC216865_FRO Submitted_20211213

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 NIA in the blank.)
Part A. LouAnn investments, LLC Property
1. Project Name
2.
Location of land -disturbing activity: C
HighwaylStreet Ocean Hwy W
n!y Brunswick City or Township Supply
Latitude 34.015220 Longitude-78.279418
3. Approximate date land -disturbing activity will commence: As soon as possible
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.3
6. Amount of fee enclosed: $ 260.00 . 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 Angie Lewis E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
LouAnn Investments, LLC
910-523-0258
Name
Telephone Fax Number
427 Ocean Hwy W
427 Ocean Hwy W
Current Mailing Address
Current Street Address
Supply NC 28462
Supply NC 28462
City State Zip
City State Zip
10_ Deed Book No. 4600 Page No.1387 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.
LouAnn Investments, LLC
[e-mail]
Name
E-mail Address
427 Ocean Hwy W
427 Ocean Hwy W
Current Mailing Address
Current Street Address
Supply NC 28462
Supply NC 28462
City State Zip
City State /� Zip
%
916
Telephone [phone]
Fax Number ���7jl`7

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
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.
�P o print na Title or Authority
it601I
Sign u (iDate
t`} Si'Y_'� _,a Notary Public of the County of r4 s i L. �--
State of North Carolina, hereby certify that tka I E t.i__)t S appeared
personally before me this day and being duly swbrn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of USG Yl e 210
atndra Ao inson Notary
Not Rubli * 4�
tar orth ou `,
North Carolina My commission expires��`" " , r7�
L
y Commission E res i/21,2025