NCC232398_FRO Submitted_20230810

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Woodlake Dam Rehabilitation
2. Location of land-disturbing activity: County Moore City or Township Vass
Highway/Street Sea Gull Dr. Latitudeoec+may degrees)35.2183 Long itude(dec mai degre s) 79 1859
3. Approximate date land-disturbing activity will commence:January 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Recreational
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):TBD (30 ac)
6. Amount of fee enclosed: $TBD ($3000) . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed I] No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Keith Allison E-mail Address [e-mail]
Phone: Office# 910-321 -7705 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Atlantic National Capital, LLC 910-321 -7705 910-303-5800
Name Phone: Office# Mobile#
PO Box 35910 2604 Fort Bragg Rd
Current Mailing Address Current Street Address
Fayetteville, NC 28303 Fayetteville NC 28303
City State Zip City State Zip
10. Deed Book No.474 Page No.900 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Atlantic National Capital, LLC [e-mail]
Company Name E-mail Address
PO Box 35910 N/A
Current Mailing Address Current Street Address
Fayetteville, NC 28303 N/A
City State Zip City State Zip
Phone: Office# 910-321 -7705 Mobile# [phone]
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 to conduct 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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
Name of Individual to Contact(if Registered Agent is a company)
(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 is registered on the NC Secretary of State business registry:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
Name of Individual to Contact(if Registered Agent is a company)

(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.
N/A
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.
D. Keith Allison Managing/Member
Type or print name Title or Authority
f B/ z 3
Signature Date
1, s' c ji 111 cum , a Notary Public of the County of &"nb(ct.r d
State of North Carolina, hereby certify that Q Vti At l 1 Stem appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this g day of NITSfi , 20 2,3
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NOTARY N - Notary
My commission expires ��y,4,f,°_/fit L.�
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Jacqueline A Smith 910-321 -7704 910-303-5807
Name Phone: Office# Mobile#
334 Glenburney Dr 334 Glenburney Dr
Current Mailing Address Current Street Address
Fayetteville, NC 28303 Fayetteville NC 28303
City State Zip City State Zip
Deed Book No.474 Page No.900 Provide a copy of the most current deed.
Landowner 3 of Record:
Janene A Aul 910-321 -7738 910-303-5812
Name Phone: Office# Mobile#
1127 Offshore Dr 1127 Offshore Dr
Current Mailing Address Current Street Address
Fayetteville, NC 28305 Fayetteville NC 28305
City State Zip City State Zip
Deed Book No.474 Page No.900 Provide a copy of the most current deed.
Landowner 4 of Record:
Cara A Spencer 910-321 -7735 910-303-5807
Name Phone: Office# Mobile#
2447 River Rd 2447 River Rd
Current Mailing Address Current Street Address
Fayetteville NC 28312 Fayetteville NC 28312
City State Zip City State Zip
Deed Book No.474 Page No.900 Provide a copy of the most current deed.
Landowner 5 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Page No. N/A
Deed Book No. N/A Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A N/A
Company 2 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 3 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 4 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 5 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A