NCC223308_FRO Submitted_20220921

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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. Elizabeth City, NC - Petco
1. Project Name
2. Location of land -disturbing activity: County Pasquotank City or Township Elizabeth City
Highway/Street 117 Tanglewood Pkwy Latitude 36.2933
Longitude -76.2987
3. Approximate date land -disturbing activity will commence: 08.10.22
,.
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.56
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? YesX No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Blake Pryor E-mail Address [e-mail]
Telephone 512.819.488 "
Cell# 512.639.1861 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Perez & Perez, LLC 252.312.8392 N/A
Name Telephone Fax Number
1720 City Center Blvd. 1720 City Center Blvd.
Current Mailing Address Current Street Address
Elizabeth City, NC 27909 Elizabeth City, NC 27909
City
State Zip city
State
M
10. Deed Book No. 1011 Page No. 934 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.
PC -Elizabeth City, NC-1-UT, LLC [e-mail]
Name E-mail Address
4747 Williams Drive
Current Mailing Address
Georgetown, TX 78633
City State
Telephone [phone]
9932NUMMM
Current Street Address
Georgetown, TX 78633
Zip city State Zip
110,11 .91 "111

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 Inc.
statrepPcogencyglobal.com
Name
E-mail Address
212 South Tryon Street Ste 1000
212 South Tryon Street Ste 1000
Current Mailing Address
Current Street Address
Charlotte, NC 28281-0001
Charlotte, NC 28281 -0001
City State Zip
City State Zip
866.775.0114
Fax Number 866.775.0115
Telephone
(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
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
city State Zip
Telephone 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 information should there be any change in the information provided herein.
Gabriel Martinez I Project Manager
Type or
�n-
izabeth City, NC-1-UT, LLc Title or Authority
nbree Development Group, Inc. 07.28.22
Date
T 6A-A C_
a Notary Public of the County of
liRahereby certify that �-74 6�le_l
State of 1118. ... "Y,- 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, this day of —,202-2-
TERESA T. ADAMS
Notary Public, State of Texas Notary
z Comm, Expires 08-30-2025
Notary ID 12541661-9 My commission expires S13012OZ Z