NCC240823_FRO Submitted_20240322

(ATTACHMENT A)
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 Environment 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: Chaney Avenue Shops
2. Location of land-disturbing activity:_Onsiow Count City or Township: Ci of Jacksonville
Highway/Street: Chaney Avenue Latitude: 34045117" Longitude: -77°25'29"
3. Approximate date land-disturbing activity will commence: March 2024
4. Purpose of development(residential,commercial, industrial, institutional,etc.): _ Commerical
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): "'cm
(L"as trtaud.i9 Abu 1")
6. Amount of fee enclosed: $ 350.00
The application fee of$225.00 for the first acre plus$125 for every additional acre(rounded up to the
next acre)is assessed without a ceiling amount. (Example: 6.4-acre application fee Is$975).
7. Has an erosion and sediment control plan been filed? Yes ❑ No u Enclosed ❑✓
8. Person to contact should erosion and sediment control Issues arise during land-disturbing activity
Name: Chris Bailey � E-mail Address: [e-mail]
Telephone#: [phone] Cell #: Fax#: _
9. 405-D Western Blvd. Same
Current Mailing Address Current Street Address
Jacksonville NC 28546
City State Zip City State Zip
10. Deed Book: 5758 Page Number: 3Q1 (Provide a copy of the most current deed)
Part B.
1. Person(s)or firm(s)who are financially responsible for the land-disturbing activity
(Provide a comprehensive list of all responsible parties on an attached sheet):
Bailey and Associates, Inc. cwbailey©baileyandassociates.biz
Name E-mail Address
405-D Western Blvd. Same
Current Mailing Address Current Street Address
Jacksonville NC 28546
City State Zip City State Zip
Telephone #: [phone] Cell #; Fax#:

2. (a)If the Financially Responsible Party is not a resident of North Carolina,give name and street address
the designated North Carolina Agent:
Name E-mall Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone #: Cell #: Fax#:
(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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone#: Cell #: Fax#:
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.
Christopher W.Bailey __ President
Type or print na Title or Authority
4 _ 017S?(dLI
LaaSitare Date
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I, _oazyj A, v tc"� ,a Notary Public of County)of ,5�®
State of North Carolina, hereby certify that d W&-j- 6/ba.1t appeared personally
before me this day and being duly sworn acknowledabove form was exe ed by him.
Witness my hand and�114," ffimlIthis � ? day of iiimano
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