NCC222731_FRO Submitted_20220810

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. Simple Twist - Dunn, NC
1. Project Name
2. Location of land -disturbing activity: County Harnett City or Township Dunn/Averasboro
Highway/StreetUS Hwy 421S Latitude 35-2949 _ Longitude -78.5959
3. Approximate date land -disturbing activity will commence: 02.01.2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.3
6. Amount of fee enclosed: $ 200.00 . 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:
NarneJulian Jessup E-mail Address [e-mail]
Telephone [phone] Cell # 910-580-1764 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
TTP East Pointe, LLC 919-934-1900
Name Telephone Fax Number
27-107 ANNETTE DRIVE 27-107 ANNETTE DRIVE
Current Mailing Address Current Street Address
Benson NC 27504 Benson NC 27504
City State Zip CRY State Zip
10. Deed Book No. 4062 Page No *J r-21
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.
TTP East Pointe, LLC johnsongtilghmanandco.corn
Name E-mail Address
27-107 ANNETTE DRIVE 27-107 ANNETTE DRIVE
Current Mailing Address Current Street Address
Benson NC 27504 Benson NC 27504
City
State Zip City
Telephone [phone] Fax Number
State
511

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
E-mail Address
Current Street Address
CRY State Zip CRY State Zip
Telephone
IX_ i! M 17, -1 In
(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
CRY
E-mail Address
Current Street Address
State Zip CRY
Telephone Fax Number
State Zip
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 attomey-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.
ryi ZS n-+< re) 6e,,(- 1 rya n a
Type or print name Title or Authority
Sign Lure Date
1,
a Notary Public of the County of f '11r-`ftf C-P
State of North Carolina, hereby certify that
appeared
personally before me this day and being
duly swam acknowledged that the above form was
executed by h irr,._,;,?.
Witness,ri�Qqd anAo I 'al seal, this c;,z day of 2 02-j—
Notary
My commission expires I Lq lq=