NCC223633_FRO Submitted_20221026

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 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.
1. Project Name EVOLVE HOLLY RIDGE MIXED USE
2. Location of land -disturbing activity: County__Onslow City or Township_,Holly Ridge_
Highway/Street Along US 17 Latitude^33.485 Longitude 77.5675^
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development: Clearing — Phase 1 — Future Apartment Development
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 46.5
6, Amount of fee enclosed: $ 46*100 = 4600 . The application fee of $100.00 per rounded acre
is assessed without a ceiling amount. NOTE: Fees are rounded up to the next whole acre and need to
be paid by separate checks to NCDENR.
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 Matt Rogers [e-mail]
Address 2918 Martinsville Road Suite A Greensboro NC 27408 Telephone [phone]
Cell # n/a Fax # _910-791-6760
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name
Current Mailing Address
City
State Zip
Telephone Fax Number
Current Street Address
City
State
M.
10. Deed Book No, 4669 Page No, 0964 Provide a copy of the most current deed.
Part B.
1. 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):
Evolve at Holly Ride LLC 910 455-1051 910-791-6760
Name Telephone Fax Number
2918 Martinsville Road Suite A Same as Mailing Address
Current Mailing Address Current Street Address
Greensboro NC 27408
City State Zip City State Zip

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:
NIA
Name E-mail Address
Current Mailing Address
City
Telephone
Current Street Address
State Zip City State Zip
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:
NIA
Name of Registered Agent
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
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 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 changp�gi the information provided herein.
Type
Signature
Manager
Title or Authority
cy
Date
N a a Notary Public of the County of u
State of North Carolina, hereby certify that Mbt���
ppeared personally
before me this day and being duly sworn acknowledged that thd by him.
Witness my hand and notarial seal, this A144day of 20_
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