NCC230066_FRO Submitted_20230111

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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 Lockwood Landing
2. Location of land -disturbing activity: County Brunswick City or Township Supply
NC Hwy 211 34.0240-78.2796
Highway/Street G Aen Swamp Rd. NW Latltude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: January 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26
6. Amount of fee enclosed: $ 2,600.00 . 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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Thomas J. Scheetz, P.E. E-mail Address [e-mail]
Phone: Office # 9 1 0-287-5900 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Norris NC, LLC 757-463-5000 757-510-4234
Name
448 Viking Drive, Suite 220
Current Mailing Address
Virginia Beach VA 23452
Phone: Office # Mobile #
448 Viking Drive, Suite 220
Current Street Address
Virginia Beach VA 23452
City State Zip City
10. Deed Book No. 4847 Page No. 321
State
Zip
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 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).
Norris NC, LLC
Company Name
448 Viking Drive, Suite 220
Current Mailing Address
Virginia Beach VA 23452
City State Zip
Phone: Office # 757-463-5000
[e-mail] / [e-mail]
E-mail Address
448 Viking Drive, Suite 220
Current Street Address
Virginia Beach VA 23452
City State Zip
Mobile # [phone]
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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
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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:
CT Corporation System
Name of Registered Agent
160 Mine Lake CT, Ste. 200
Current Mailing Address
Raleigh NC 27615
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
By TMPR, LLC Its Manager
Raymond L. Go ' b Raymond L. Gottlieb, TMPR, LLC, Manager
Type or pri e Title or Authority
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Signature Date
I, G
Cynthia G. Shank a Notary Public of the t of Virginia Beach
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State of Ne444 , hereby certify that Raymond L. Gottlieb 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 I CS day of August 20 22
Notary
Seal
My commission expires 10/31/2024
Cynthia G. Shank
Notary Public
REG. # 213972
MY COMM SSION EXPIRES OCTOBER 31 2024