NCC231604_FRO Submitted_20230524

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT _
No parson may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and on acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Gection, N.C. Department ofEnvironment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Wilmington Surgical
2. Location of land-disturbing activity: County New Hanover City or Township Wilmington
273� Iron Gate Drive 34.1910 77 S14O
Highway/Street Latitude Longitude ongitude- �
3. Approximate date land-disturbing activity will commence.-O5/25/2O23
4. Purpose ofdevelopment(reoidentim|, oommercia|, induatrim|, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including of-ait n 1
off-site borrow '50
8. Amount of fee enclosed: $ 130.00 . The application fee of$65.00 per acre (rounded
upbo the next acre) ia assessed without e ceiling amount (Exempie: aQ-acne application fee is*585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name William Adams E-mail Address tada[[e-mail]
Telephone 910~443-8753 Cell# 910-443-8753 Fax# N/A
8. Landowner(s) of Record (attach accompanied page to list additional owners):
BW1T Pnopertiea, LLC 910-763-7363 aw 142 910-251'8280
Name Telephone Fax Number
1414 Medical Center Drive 1414 Medical Center Drive
Current Mailing Address Current Street Address
Wilmington NC 28401 Wilmington NC 28401
city State Zip City State Zip
10. Deed Book No.60 Page No.314 Provide e copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide o
comprehensive list of all responsible parties onan attached aheed):
BMTPnopmrties. LLC odnnin@vvi|mninAtonaung|oo|.corn
Name E-mail Address
1414 Medical Center Drive 1414 Medical Center Drive
Current Mailing Address Current Street Address
Wilmington NC 28401 Wilmington NC 28401
C{hy State Zip City State Zip
S1078� 73�3 �� 142 Fax 81O251 8296
Telephone - - ex Number - -

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:
Name E-mail Address
Current Mailing Address Current Street Address
city State Zip Cih/ State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed noma, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party ioo 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 beet of my knowledge and belief and was provided
by rna under oath (This form must be signed by the Financially Responsible Person if an individual
or his attornay-in-toci, or if not an individum|, by on mffiuor, diractor, portner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information should there ba any change in the information provided herein.
Gregory Bebb Managing Member
Type or print nenna Title or Authority
O5/24/2O23
/Gignatur�{/ / 3YZ 14A� Dat
|. ()- m~ � � � v � � S . a Notary Public of the County of
�State of North Carolina, hereby certify
ifv that �� � '`f %W A)����
appeared
personally before me this day and being duly s�,orn`�knovv|edged that the above form was
executed by him.
VV|tneea my hand and notarial
seal, this ^ day of Moou~�\^ 20 10�_�^
Notary
_'
K«v o�D1rDiG8iOD �r����
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