NCC230886_FRO Submitted_20230418

Check if this project is ARPA-funded 0
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Site Development Plan for Dr. Santhosh Augustine
*Jf this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which You applied for funding through the Division of Water Infrastructure(DWI).
Z. Location of land-disturbing activity: County Robeson City or Township Lumberton
Highway/StreetWoodbridge Dr. Latitude(dec-imal degrees)34.6412 Longitude(decimal degrees)-78.99584
3. Approximate date land-disturbing activity will commence:March 2023
4. Purpose of development(residential,commercial, industrial, institutional,etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.30 Acres
6. Amount of fee enclosed: $200.00 _. The application fee of$100.00 per acre(rounded
up to the next acre)is assessed without a ceiling amount (Example: 8.1 0-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes F-1 Enclosed No F-1
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dr. Santhosh Augustine E-mail Address [e-mail]
Phone: Office# *-7
910-733-2007 Mobile# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Sarina Three Investments, LLC. 910-733-2007
Name Phone: Office# Mobile#
501 Londonderry Drive 501 Londonderry Drive
Current Mailing Address Current Street Address
Lumberton, NC 28358 Lumberton NC 28358
City State Zip city State Zip
1924 708
10. Deed Book No. Page No. Provide a copy of the most current deed.

Part B.
1. who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page the landowme/(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Dr. SaMthos6Augustine sEknth0shEkugust'ne@hot00a'i.co00
Company Name E-mail Address
�M� Londonderry �� ' ��1 U � � K� '
=� . =r|�f�� =� . ~-���=0�=����� =�UYfe
Current Mailing Address Current Street Address
Lumberton, NC 28358 Lumberton, NC 28358
city State Zip city State Zip
��M_���-������
Phone: Q�oe# = ^° ^ == =-�"' Mobile#
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 toconduct 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 E-mail Address
Current Mailing Address Current Street Address
city State Zip City State Zip
Phone: Offine# Mobika#
Name cn Individual zo Contact(if Registered Agent isacompany)
(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 ia 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 bz Contact(if Registered Agent|oecompany)

(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.
Santhosh Augustine Owner
Type or print name Title or Authority
Signature Date
-------------------------------------------- ------------------------------------------------------ ---------------
i, t)�� a Notary Public of the County of
L. N
State of North Carolina,hereby certify that_SCAQS v rt UQ A.-N- appeared personally
before me this day and being duly sworn acknowledged that the ab6ve form was executedby him/her.
Witness my hand and notarial seal, this �,? day of aVAU0f(J 20
TAR le
O Al
My commission expires C) _ Ao-
0
ON
is kill

Continued from Items 9 & 10 in Part A of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Sarina Three Investments, LLC. 910-733-2007
Name Phone: Office# Mobile#
501 Londonderry Drive 501 Londonderry Drive
Current Mailing Address Current Street Address
Lumberton NC 28358 Lumberton NC 28358
City State Zip city State Zip
'7C
Deed Book No.2369 Page No. t 55 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip city State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip city State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item I in Part B of the Financial ResponsibilitylOwnershio Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip city State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip city State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip city State Zip
Phone: Office# Mobile#