NCC223300_FRO Submitted_20220922

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 NIA in the blank.)
Part A.
Project Name NC Goldsboro Hwy. 70
2. Location of land -disturbing activity: County Wayne City or Township Fork Township
Highway/Street US Hwy. 70 West River Basin: Neuse
Latitude N 35.4262 Longitude W-78.0629
(Lat and Long given to 4 decimal places it XX.xxxx N,-YY.yyyy W. not XX xx'xx" N, -YY yy' yy" W)
3. Approximate date land -disturbing activity will commence: August, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.0
6. Amount of fee enclosed: 600 The application fee of $65.00 $100 per acre (rounded up to the next
acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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:
Name Jonathan Cochrane E-mail Address icochrane(&realtvlinkdev.com
Telephone [phone] Cell # 803-528-9798 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HWB of North Carolina, LLC 919-734-1111 NIA
Name Telephone Fax Number
PO Box 189 6174 US Hwy 70 West _
Current Mailing Address Current Street Address
Kinston NC 28502 Kinston NC 28502
City State Zip City State Zip
10. Deed Book No. 1691 Page No. 83 Provide a copy of the most current deed.
Part B.
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):
NC Goldsboro Hwy 70, LLC
Name
201 River lace Suite 400
Current Mailing Address
Greenville SC 29601
City State Zip
Telephone [phone]
icochrane0realtv1inkdev.com
E-mail Address
201 River lace Suite 400
Current Street Address
Greenville SC 29601
City State Zip
Fax# [phone]

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:
Corporation Service Company
Name
2626 Glenwood Avenue
Current Mailing Address
Raleigh NC 27608
City State Zip
Telephone [phone]
mike.obrientaakscglobal.com
E-mail Address
Current Street Address
Raleigh NC 27608
City State Zip
Fax#
(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:
NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone,
E-mail Address
Current Street Address
City State Zip
Fax#
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 by any change in the information provided herein.
Philip J. Wilson
Type or print name
Manager
Title or Authority
-7 if 5A 7-
Signature Date
I, a Notary Public of the County of 6(t¢hYr 0
State of North Carolina, hereby certify that Al/i) D � aLOO 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 o 0 �21
Notary
Seal
My commission expires . Di C. HART
Notary Pub"C_State of South Carolina
My Commission Expires
August71,2026