NCC221652_FRO Submitted_20220504

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. Waterlei h Phases 5 & 6
1. Project Name g
2. Location of land -disturbing activity: County CUrrltu& City or Township Moyock
Highway/Street Tulls Creek Rd. Latitude 36.518800 Longitude -76.144053
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
S. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ . 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:
NameJustin M. Old E-mail [e-mail]
Telephone [phone] Cell # 757-816-2006 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Allied Properties, LLC
252-435-2718
Name
Telephone Fax Number
417-D Caratoke Hwy.
SAME
Current Mailing Address
Current Street Address
Moyock NC
27958
City State
Zip City State Zip
10. Deed Book No. 1419
Page No. 882 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.
Allied Properties, LLC
[e-mail]
Name
E-mail Address
417-D Caratoke Hwy.
SAME
Current Mailing Address
Current Street Address
Moyock NC
27958
City State
Zip City State Zip
Telephone [phone] Fax Number 252-232-9040

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
Current Mailing Address
city
E-mail Address
Current Street Address
State Zip city
Telephone Fax Number,
State Zip
(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:
Justin M. Old
Name of Registered Agent
417-D Caratoke Hwy.
Current Mailing Address
Moyock NC 27958
city
State Zip
Telephone [phone]
[e-mail]
E-mail Address
SAME
Current Street Address
City State Zip
Fax Number 252-232-9040
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.
Type or print name
Title or Authority
Date
I, 4 d7-_Xd__5r , a Notary Public of the County of
State of North rolina, hereby certify that U o�_ appeared
personally before me this day and being duly orn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day ofAlt,�L­� .20 21
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