NCC230756_FRO Submitted_20230324

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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Landingat Mill Creek Phase V
1. Project Name
2. Location of land -disturbing activity: County Onslow City or Township Sneads Ferry
Highway/Street NC 210 Latitude 34.3709 Longitude 77.7117
3. Approximate date land -disturbing activity will commence: January 1 , 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 41
6. Amount of fee enclosed: $ 2665.00 . The application fee of $65.00 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 Kenneth Pratt E-mail Address [e-mail]
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NC Hwy 210, LLC
Name Telephone Fax Number
5950 Berkshire Lane, Suite 800
Current Mailing Address Current Street Address
Dallas, TX 75225 Same
City State Zip City State Zip
10. Deed Book No. 4043 Page No. 9 Provide a copy of the most current deed.
Part B.
4. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
NC Hwy 210, LLC [e-mail]
Name E-mail Address
5950 Berkshire Lane, Suite 800
Current Mailing Address
Dallas, TX 75225
City
Same
Current Street Address
State Zip City
Telephone [phone] Fax Number,
State
Zip

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Capitol Corporate Services, Inc.
Name E-mail Address
120 Penmarc Dr Ste 118 Same
Current Mailing Address Current Street Address
Raleigh NC 27603 Same
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:
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 P,xecute instruments for the Financially Responsible Person). I agree to provide
corrected inforrrralion should there be any change in the information provided herein.
Type
Sign
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Title or Authority
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Date
I,—oweY.. bwn �; �%] K+��� , a Notary Public of the County of
State of North Carolina her i pat7rel,y cert fy thatappeared
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 z L day of &OWYter, 20 Z
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Ann Vargas RoblezYPf3MSUTEOFTEW otaryMARCH !, 20
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