NCC221788_FRO Submitted_20220531

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. Middle Creek Village Phase 1
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Bolivia
Highway/Street U.S. Highway 17 Business Latitude 34003'12°N Longitude 78009'57°W
3. Approximate date land -disturbing activity will commence: April 7, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 45.42 AC
6. Amount of fee enclosed: $ 46 AC*$100=$4,600 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 Jeff Leone E-mail [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Tamarack Land -Middle Creek, LLC [phone]
Name Telephone Fax Number
1536 Beachcomber Blvd. 1536 Beachcomber Blvd.
Current Mailing Address Current Street Address
Waconia MN 55387-1055 Waconia MN 55387-1055
City State Zip City State Zip
10. Deed Book No. 04770 Page No. 1396 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.
Tamarack Land -Middle Creek, LLC [e-mail]
Name E-mail Address
1536 Beachcomber Blvd 1536 Beachcomber Blvd
Current Mailing Address Current Street Address
Waconia MN 55387-1055 Waconia MN 55387-1055
City State Zip City State Zip
Telephone [phone] 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:
Capitol Corporate Services, Inc
Name E-mail Address
120 Penmarc Drive 120 Penmarc Drive
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27603
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
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 Leone
Authorized Signatory
Type or print name Title or Authority
Sign Date
I, pul 1 P- SELLO- , a Notary Public of the County of Ojj jQfj
State of North Carolina, hereby certify that J Er-F L F D A) F 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 day of MUC �f , 20.21
NotEK
Seal
My commission expires
MICAYLA MIRABELLA
Notary► Public, State of New Jersey
Corrwntssion # 5ol8M
�l' n December 21, 210