NCC231905_FRO Submitted_20230621

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. (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 Senter Farm-Phase 1
2. Location of land-disturbing activity: County Harnett City or Township Hectors Creek
Highway/Street US 401 N _ Latitude 35.520 _Longitude -78.812
3. Approximate date land-disturbing activity will commence:Fall 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 33.0 acres
6. Amount of fee enclosed: $ 2.145.00 . 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 The CSC Group LLC-Steve George E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
VLS Real Estate LLC
Name Telephone Fax Number
4141 Parklake Avenue STE 200 Same
Current Mailing Address Current Street Address
Raleigh, NC 27612-2333 Same _
City State Zip City State Zip
10. Deed Book No. 1876 Page No. 280-305 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.
The CSC Group LLC-Steve George [e-mail]
Name E-mail Address
10030 Green Level Church Rd, Suite 802#149 Same
Current Mailing Address Current Street Address
Cary, NC 27519 Same
City State Zip City State Zip
Telephone [phone] Fax 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 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:
The CSC Group LLC-Steve George [e-mail]
Name of Registered Agent E-mail Address
10030 Green Level Church Rd, Suite 802#149 Same
Current Mailing Address Current Street Address
Cary, NC 27519 Same
City State Zip City State Zip
Telephone [phone] 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
correct d information should there be any change in the info ation provided herein.
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Type or print n fn Title or Au rity
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Signatur/ Date
I, S-1-r p` / A V iF i , a Notary Public of the County of lt9 k
State of North C rolina, hereby certifythat S � �+. � cc w&-s Co.o-sgt_ appeared
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 _ day of 5`^1 1-1 , 20 `� '
oolsiliwoN
`n Notary
? gK�j r-y. Public
county - My commission expires h ;CI 2 a 2 3
My Comm. Exp.
02-05-2023
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