NCC220739_FRO Submitted_20220215

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JAN 2 8 2022
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act bef effii
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. Family Acres
1. Project Name
E
i
11
Location of land -disturbing activity: County Brunswick City or Township Bolivia
Highway/Street Johnson Trail S.E. (5R1611) Latitude 3405'20.61 "N Longitude 78"5'29.90'W
Approximate date land -disturbing activity will commence: Upon Erosion Control Approval
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.79 acres
6. Amount of fee enclosed: $ 200 . 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 Sam Chadwick Email Address [e-mail]
Telephone [phone]
Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to fist additional owners):
Sam Chadwick [phone]
Name Telephone Fax Number
7422 Cordoba Cir Apt 104 7422 Cordoba Cir Apt 104
Current Mailing Address Current Street Address
Leland NC 28451 Leland NC
City State
10. Deed Book No. 4556/4729
Zip City
Page No. 940/431
State
28451
Zip
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.
Sam Chadwick [e-mail]
Name
7422 Cordoba Cir Apt 104
Current Mailing Address
Leland NC
City State
Telephone [phone]
E-mail Address
7422 Cordoba Cir Apt 104
Current Street Address
28451 Leland
Zip City
Fax Number
NC 28451
State Zip

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.
Christie Chadwick [e-mail]
Name
7422 Cordoba Cir Apt 104
Current Mailing Address
Leland NC
City State
Telephone [phone]
E-mail Address
7422 Cordoba Cir Apt 104
Current Street Address
28451 Leland NC 28451
Zip City State Zip
Fax Number
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.
Jose Delgado [e-mail]
Name E-mail Address
9531 104th st 9531 104th st
Current Mailing Address Current Street Address
Ozone Park NY 11416 Ozone Park NY 11416
City State Zip City State Zip
Telephone [phone] Fax Number
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.
Paul D'Angelo
Name
9531 104th st
Current Mailing Address
Ozone Park NY
City State
Telephone [phone]
E-mail Address
9531 104th st
Current Street Address
11416 Ozone Park
Zip City
Fax Number
NY
State
11416
Zip

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:
Sam Chadwick [e-mail]
Name
7422 Cordoba Cir Apt 104
Current Mailing Address
Leland NC 28451
City State Zip
Telephone [phone]
E-mail Address
7422 Cordoba Cir Apt 104
Current Street Address
Leland NC 28451
City State Zip
Fax Number
(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Christie Chadwick [e-mail]
Name E-mail Address
7422 Cordoba Cir Apt 104 7422 Cordoba Cir Apt 104
Current Mailing Address Current Street Address
Leland NC 28451 Leland NC 28451
City State Zip City State Zip
Telephone [phone] 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

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
Telephone
State
Zip
City State Zip
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.
Sam Chadwick
Type or print rtame•-�
igna
Owner
Title or Authority
Date
I, — a Notary Public of the County of _7RN k L AG
State of North Carolina, hereby certify that f7 Z" r appeared
personally before me this day and being du y sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this �M _day ofV,)c,4 , 20 rc)-\
L My commission expires -

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.
ChrAS-h-e- ChodwJ(K-- CO Quo n�
T e or print e Title or, Authority
natur Date
----------------------------------------------- ------------------ ---------------------------------------------------
----------------
'��7c�ri��o. \' , a Notary Public of the County of U c l�\CAL
State of North Carolina, hereby certify that ��r � s e ��s W�C� 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 !ay day of 20�r
`Sl;l,ll111J171!!1y!!f!!'fI ,' �
IFS, °- Not
:`may Seal
vj ��,���{ U` My commission expires
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03 �C
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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.
�:Y [Go ('-0- oW*-K--�
Type or print e Title or Authori
Sign re Date
I, Al
_�7�,�„ti,� Leo , a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowl dged that the above form was
executed by him.
Witness my hand and notarial seal, thisday of 20
of
My commission expires Lk
Mgylecs; ..; p, p �lese_

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.
6Q iL, [5k."I (DAI A C b - J)rJNR�&
Typ or print name Title or Author'ty
Zq Z—�
SigNature Date
a Notary Public of the County of
State of North Carolina, hereby certify that�c�% I \ appeared
personally before me this day and being duly sworn ackno ledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of cjgQ,-j-\N-)e r 20�\
,,wFue5s��siiyi unrridryrr
N to
SealCO S
My commission expires
NOTARY
Uj
DUBLlC
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Additional landowners:
Landowner(s) of Record (attach accompanied page to list additional owners);
Christie Chadwick [phone]
Name Telephone Fax Number
7422 Cordoba Circle #104
Current Mailing Address Current Street Address
Leland NC 28451
City State zip City State
Landowner(s) of Record (attach accompanied page to list additional owners):
Jose Del ado [phone]
Name Telephone Fax Number
9531 104th St
Current Mailing Address
Ozone Park NY 11416
City
State
Current Street Address
Zip City
State
Landowner(s) of Record (attach accompanied page to list additional owners):
Patel D'An elo [phone]
Name Telephone Fax Number
9531 104th St
Current Mailing Address Current Street Address
Ozone Park NY 11416
City
State Zip City
State
Zip
Zip
Zip