NCC221184_FRO Submitted_20220329

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. Villari Brothers Parkin Ex ansion
1. Project Name_ g p
2. Location of land -disturbing activity: County Duplin City or Township Warsaw
Highway/Street 135 Carter Best Rd Latitude 34.98655ON -Longitude 78.082148W
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.4
6. Amount of fee enclosed. $ 400.00 . 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 Gerald Matthews E-mail Address [e-mail]
Telephone [phone] cell # 910-289-7500 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Micro Land Group, LLC 910-293-6594
Name Telephone Fax Number
135 Carter Best Rd 135 Carter Best Rd
Current Mailing Address Current Street Address
Warsaw NC 28398 Warsaw NC 28398
City State Zip City State Zip
1874 1958 435 184
10. Deed Book No. Page No. 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.
Micro Land Group, LLC [e-mail]
Name E-mail Address
135 Carter Best Rd 135 Carter Best Rd
Current Mailing Address Current Street Address
Warsaw NC 28398 Warsaw NC 28398
City State Zip
Telephone_ 910-293-6594
City
Fax Number
State
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. -
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:
Joseph Villari
Name of Registered Agent
1015 Ashes Dr, Suite 102
Current Mailing Address
Wilmington NC 28405
City State Zip
Telephone
E-mail Address
Current Street Address
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 -facia, 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 Villari CFO
Type or print name Title or Authority
Signature Date
a Notary Public of the County of C]c�.�,� to
State of North Carolina, hereby certify that 'L_)�a n-) 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 ti day of C—ChrL&ar 20 EL
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Notary
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