NCC222507_FRO Submitted_20220715

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. Project Name Pierce Terrace Site
2. Location of land -disturbing activity: County Gates City or Township Sunbury
Silver Springs Rd 36,431500 7661:;i19"1
Highway/Street LatltUde(decimal degrees) Longltude(decimal degrees)
3 Approximate date land -disturbing activity will commence: August 22, 2022
4 Purpose of development (residential, commercial, industrial, institutional, etc.) Restoration
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas). 27.7 acres
6 Amount of fee enclosed: $ 3,000.00 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 ❑x No ❑
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Worth Creech E-mail Address [e-mail]
Phone: Office # 919-755-9490 Mobile # [phone]
9 Landowner(s) of Record (attach accompanied page to list additional owners)
Helen Hofler Pierce 252-465-8851 252-340-0525
Name Phone: Office # Mobile #
356 Silver Springs Rd 356 Silver Springs Rd
Current Mailing Address
Sunbury, NC 27979
City
Current Street Address
Sunbury, NC 27979
State Zip City
State
Zip
10. Deed Book No 139 _ Page No 610 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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies)
Restoration Systems LLC [e-mail]
Company Name E-mail Address
1101 Haynes St, Suite 211 1101 Haynes St, Suite 211
Current Mailing Address Current Street Address
Raleigh, NC 27604 Raleigh, NC 27604
City State Zip City State
Phone: Office # 919-755-9490 Mobile # [phone]
Zip
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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.
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.
George Howard CEO
Type or print name Title or Authority
C24, 5/23/22
Signature Date
1, a Notary Publicofthe County of L �G
State of North Carolina, hereby certify that aee iwaf J appeared personally
before me this day and being duly sworn acknowledgled that
tt&'�
the above form was executed by him/her-
Witness my hand and notarial seal, this 23 day of 20 2 Z
Seal
.,,,,1�11I 11111Ir/�rlrr ,!
N
CAN
10, -
\G C )
pUB\-
'rlrflll rl ll�r���l�"''
Notary /%
My commission expiresy�IJ�I

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
S&M Farms LLC 252-465-8603 252-340-1706
Name
PO Box 130
Current Mailing Address
Sunbury, NC 27979
Phone: Office # Mobile #
539 NC 32 South
Current Street Address
Sunbury, NC 27979
City State Zip City
Deed Book No .286 Page No 306
Landowner 3 of Record
State Zip
Provide a copy of the most current deed
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City T State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No
Landowner 5 of Record
Name
Current Mailing Address
City
Deed Book No.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No Provide a copy of the most current deed

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address J Current Street Address���
City State Zip City State Zip
Phone: Office # Mobile #