NCC223245_FRO Submitted_20220916

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 mom*pbab|m erosion and sedimentation control plan have been completed and approved by the Lund
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please typo or print and, if the question is not opp|ioob|a or the e-mail address or phone
number isunavailable, p|enw N/A in the blank.)
Part A.
x� Park �� ��
��8��K�� ��� Phase 1. pu�octNom �^ " ^^ ^^`�
2. Location ufland-disturbing activity: Coun =runsw' cL-City orTovnnhiLUaDd
NC Hwy B7 (K8auo RdJ ���1 ��) -78.1�� �
Highway/Street Lati�ud�mvm=u������.�Longitudewom"�/u°ov�o` ^ '
��6�mt�(O����[j �A��
3. Approximate date land -disturbing activity will commence: September - ' '-~^-�
����./����f'�l�
4. Purpose ofdewdopment(nanidenUa|.commercial, industho|.in�duUnna|.eb�.):' ^ '= `' ^
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): ^ ���
S. Amount uffee enclosed. 2700 The application fee of$1O0.00per acre (rounded
uptnthe next acre) imassessed without aceiling amount (Exmmp|o:8.10-mon*application fee iw$90O).
Checks should beaddressed toNCDE{J.
p�
7. Has mnerosion and sadinnantcontrol plan been filed? Yos[] Enclosed�s No [�
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
/�t��\��� ���Ui�U����[�rt� [e-mail]
Nmm ~^^ ^^'' ^^" '`'' E-mail Address "= '
71�_^���_1���
Phone: Office ^ '� -`�� '�'`° Mnbile#
0. Landowner(s) of Record (attach accompanied page to list additional owners):
Grayson Park Development, LLC 719-/199-1373
Nam* Phone: Offion# Mobile #
711 Carolina
Beach ��� Mailing)
\
, .. ^������"|�l����������..^"��� \����00���l��.".��|/|�l(�/
Current Mailing Address Current Street Address
Carolina
Beach ��/� �����
~��I��.|D� ^^����. . .��� ����=
City State Zip City State Zip
��O� ��A
10. Deed Book No.'~~^^ Page No. '~~ Provide ocopy nfthe 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).
Grayson Park Development, LLC [e-mail]
Company Name
711 Carolina Beach Ave
Current Mailing Address
Carolina Beach NC 28428
City State Zip
Phone: Office# 719-499-1373
E-mail Address
Current Street Address
(Same as Mailing)
City State Zip
Mobile #
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:
Michelle Elaine Carlisle
Name of Registered Agent
8620 River Rd.
Current Mailing Address
Wilmington NC 28412
City
State Zip
Phone: Office# [phone]
ame of Individual to
E-mail Address
(Same as mailing)
Current Street Address
City State Zip
Mobile #
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.
01,11,
I
Manager
Title or Authority
7.-/T^22
a Notary Public of the County of N
of Y,State o orth Carolina, hereby cefify that 61-t &tr (T11 e'W(ir)qq 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 1 5tay of 205�
c
HAR ` .., • • ` �' Notary
• -- = My commission expires O �o2C0
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