NCC223654_FRO Submitted_20221025

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 Eastfield Retail Block B
2. Location of land -disturbing activity: Count Johnston City or Township Selma
H Ighway/Street U S 70A _ Latltude(decimal degrees) 35.5187 Long Itude(decimal degrees)-78.2856
3. Approximate date land -disturbing activity will commence: 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20.00
6. Amount of fee enclosed: $ 2,000.00 . 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 ❑x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mark McDonnell E-mail Address [e-mail]
Phone: Office # 919-965-5661 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Eastfield Associates, LLC 919-965-5661
Name Phone: Office # Mobile #
101 S. Raiford Street, Suite 200 101 S. Raiford Street, Suite 200
Current Mailing Address Current Street Address
Selma, NC 27576 Selma, NC 27576
City State Zip City State Zip
10. Deed Book No. 05254 Page No. 0942 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Eastfield Associates, LLC [e-mail]
Company Name E-mail Address
101 S. Raiford Street, Suite 200 101 S. Raiford Street, Suite 200
Current Mailing Address
Selma, NC 27576
Current Street Address
Selma, NC 27576
City
State Zip
City
Phone:
Office # 919-965-5661
Mobile #
State
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:
N/A
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:
N/A
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)

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:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
N/A
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.
CAIJ
Type or priV name i� Title or Au ority
S nature Date
a r-' 1 a Notary Public of the County of U0,11'a
State of North Carolina, hereby certify that . G appeared
personally before me this day and being duly sworn acknowledged hat the above form was
executed by him.
Witness my hand and notarial seal, this day of 20
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