NCC230088_FRO Submitted_20230124

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 Salvo Marina
2. Location of land -disturbing activity: County Dare City or Township Rodanthe
NC 12 35.541675-75.473311
Highway/Street Latltude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Fall 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Multi -Family Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.2
6. Amount of fee enclosed: $ 400 . 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.
Q
Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Sumit Gupta E-mail Address sguptaPicrsaga.com
Phone: Office # 252-441-9003 X 1116 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Salvo Marina 27446, LLC 252-441-9003 X 1116 252-207-8997
Name
1314 S. Croatan Hwy Suite 301
Current Mailing Address
Kill Devil Hills, NC 27948
City State
10. Deed Book No. 2066
Phone: Office # Mobile #
1314 S. Croatan Hwy Suite 301
Current Street Address
Kill Devil Hills, NC 27948
Zip City State Zip
Page No. 734 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).
Salvo Marina 27446, LLC
Company Name
1314 S. Croatan Hwy Suite 301
Current Mailing Address Current Street Address
Kill Devil Hills, NC 27948 Kill Devil Hills, NC
City State Zip City State
Phone: Office # 252-441-9003 X 116 Mobile # [phone]
E-mail Address
1314 S. Croatan Hwy Suite 301
27948
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:
Prem Gupta
Name of Registered Agent
P© Box 90
Current Mailing Address
Kill Devil Hills, NC 27948
City
State
Phone: office # 252-441-9003
[e-mail]
E-mail Address
1314 S. Croatan Hwy Suite 301
Current Street Address
Kill Devil Hills, NC 27948
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
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)

(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.
Type or pjtt name
Sign
Title or Authority
1�1
Date
I, ► u-p.9zrW4Q_ , a Notary Public of the County of Ctjfr O�f—
1
State of North Carolina, hereby certify that ('ems (--I --- 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 -[C�day of 20 ,� Z
��,.QQ Gudmun ti.
=r4y; OIAR. •y � My commission expires
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