NCC221783_FRO Submitted_20220510

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 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 GreenHawk Townhomes
2. Location of land -disturbing activity: County Harnett City or Township Lillington
Highway/Street NC-210 Highway Latitude 35deg2756.6" N Longitude 78deg47'18.4"W
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 32AC
6. Amount of fee enclosed: $ 2080.00 . 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 Jeff White E-mail Address [e-mail]
Telephone [phone] Cell # 919-422-5741 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LaRue Powell
Name Telephone Fax Number
7036 Rouse Road Same
Current Mailing Address Current Street Address
Holly Springs NC 27540 Same
City State Zip City State Zip
10. Deed Book No 3826 Page No. 0333 Provide a copy of the most current deed.
Part B. 3826 0329
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):
Jeff White / GreenHawk Corporation [e-mail]
Name E-mail Address
1330 Sunday Drive Same
Current Mailing Address
Raleigh NC 27607
City State Zip
Telephone [phone]
Current Street Address
Same
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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
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 -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.
Jeff White
T or pri t a e
S1 ure
MXaK,EF-
Title or Authority
Date
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I, v c n 61 cCS a Notary Public of the County of
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State of North Carolina, hereby certify that z 1'(i K. Whitt appeared
personally before me this day and being duly swo acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this C1
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