NCC222021_FRO Submitted_20220607

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1
2.
3.
4
Project NameAvalon
Location of land -disturbing activity: CountyBrunswick City orTownsNpBolivia
N F,Kr.(u� p, Emmprcenformv pip 3¢Ao15S 17 -78 a 1 iii 2;j�]
Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
Approximate date land -disturbing activity will commence: May 2022
Purpose of development (residential, commercial, industrial, institutional, etc.}: Residential
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas).
reviousl aid
2.47
6 Amount of fee enclosed: $ V y V The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed p No p
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
NameJason Jones E-mail Address)[e-mail]
Phone: Office # NA
Mobile # [phone]
9 Landowner(s) of Record (attach accompanied page to list additional owners)
Glenwood Homes LLC 919.578.1402 NA
Name Phone: Office # Mobile #
P.O. BOX 90427 9220 Fairbanks Dr. I Suite 120
Current Mailing Address Current Street Address
Raleigh NC 27675 Raleigh NC 27613
City State Zip City State
Zip
10. Deed Book No. - Page No. Provide a copy of the most current deed

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Glenwood Homes LLC
Company Name
P.O. Box 90427
Current Mailing Address
Raleigh NC 27675
City State Zip
Phone: Office # 91 9.578.1402
114 _C� L 1 etj u..'i +Li� i St•�'Yi�3 LGIV►i�
E-mail Addre s
9220 Fairbanks Dr. I Suite 120
Current Street Address
Raleigh NC 27613
City State Zip
Mobile # NA
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
IN
Name of Registered Agent
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Phone: Office # Mobile #
NA
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
NA
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
NA
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
10FO
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Thomas Quackenbush Managing Member
TypMame
Si ure
Title or Authority
5/4/2022
Date
a Notary Public of the County of YnIanSorr
State of North Carolina, hereby certify that '::F�(2 acc45 GkUQ4 Ken hush appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 9_day of KC4 , 20 zz
Wary
�%1 My commission expires 10