NCC222423_FRO Submitted_20220714

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 Ba line North Phase 1
2. Location of land -disturbing activity: County Brunswick County City or Township
Highway/Street Thomasboro Rd Sw _Latitude 33.919874 Longitude= 78.556094
3. Approximate date land -disturbing activity will commence:
4
5
06/01 /2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 48 acres
6. Amount of fee enclosed: $ 4,800 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No_ _X
7
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Larry Gordon E-mail Address LGordonCo7criteriaconstruction.com
Telephone Cell # 347-680-7150 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Thomasboro Landco, LLC 251-850-5188
Name Telephone
11118 US 31
Current Mailing Address
_Spanish Fort AL
City State
Current Street Address
527 Sam
Zip City
State
Fax Number
Zip
10. Deed Book No. 4648 Page No. 1178-1194 Provide a copy of the most current deed.
Part B.
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):
Thomasboro LandCo, LLC _ _PauI@criteriadeveloi)ment.com
Name E-mail Address
_11118 US 31
Current Mailing Address
Current Street Address
Spanish Fort AL 36527 Sa
City State Zip City
State
Zip
Telephone_251-850-5188 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:
Cogency Global _
Name
212 S. Trvon St, Ste 1000
Current Mailing Address
Charlotte, NC 28281
City State Zip
Telephone [phone]
Karen (a-)coQencvalobal.com
E-mail Address
212 S. Trvon St, Ste 1000
Current Street Address
Charlotte, NC 28281
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
Telephone
E-mail Address
Current Street Address
State Zip 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 kAt_r
infor should there be any change in the information provided herein.
i bit ry_C Y
Type gf-prir game Title or Authority
Signature
11/V
Date
I, Q ' -,a Notary Public of the County of �7a1 dyy i n
State of N &t hereby certify that -E( 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,
MartyS son Deas
Notary Public, Alabama State at Large
r
this U r6ay of , 20 2 Z
Notary
My commission expires 4 r 0 0 a-�r