NCC203615_MODIFICATION Supporting Documents_20230324 (2)

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. CALABASH STATION
1. Project Name
2.
Location of land -disturbing activity: County BRUNSWICK City or Township SHALLOTTE
Highway/Street CALABASH ROAD Latitude 3305614.50"N Longitude 7803557.95"W
3. Approximate date land -disturbing activity will commence: COMMENCED 9.1.2020 (Existing permit)
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):66.71 ACRES
6. Amount of fee enclosed: $ o (NO CHANGE IN DESIGN). 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 X No Enclosed _
8. Person to contact should erosion and sediment control issues arlse during land -disturbing activity:
Name Bryant Spencer E-mail Address [e-mail]
Telephone [phone] Cell # 910-308-0804 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CALABASH STATION LLC
910-486-4864 910-485-0463
Name
Telephone Fax Number
2919 BREEZEWOOD AVE
2919 BREEZEWOOD AVE
Current Mailing Address
Current Street Address
FAYETTEVILLE, NC 28303-5501
FAYETTEVILLE, NC 28303-5501
City State Zip
City State Zip
10. Deed Book No. 4430 page No 426 Provide a copy of the most current deed.
Part B.
1. 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.
Calabash Station, LLC
[e-mail]
Name
E-mail Address
2919 Breezewood Avenue, Suite 100
2919 Breezewood Avenue, Suite 100
Current Mailing Address
Current Street Address
Fayetteville NC 28303
Fayetteville NC 28303
City State Zip
City State Zip
Telephone [phone]
Fax Number 910-485-0463

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.
David Vannoy Manager
I-yp ntji,amp, Title or Authority
.� /
Date
I, rYe Lr- 0" , a Notary Public of the County of
State of North Carolina, hereby certify that .r d Vt.,n'O appeared
personally before me this day and being duly sworn acknowledgetil that the above form was
executed by him.
Witness my hand and notarial seal, this day of OxOv- 20 3
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Notary /
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