NCC222231_FRO Submitted_20220707

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
Polywood Facility Expansion
2. Location of land -disturbing activity: County Person City or Township Woodsdaie Township
Highway/Street Jim Thorpe Hwy Latltude(decimal degrees) 36.4472 Longltude(decimal degrees)-78.9288
3. Approximate date land -disturbing activity will commence: 6/1 /2022
4 Purpose of development (residential, commercial, industrial, institutional, etc.) industrial
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas) 31.2 ac
6 Amount of fee enclosed: $ 3200 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 ■ No ❑
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Jason Seaman. PE E-mail Address [e-mail]
Phone: Office # 980-273-9406 Mobile #
9 Landowner(s) of Record (attach accompanied page to list additional owners).
BV/Weston JT LAND LLC 216-337-8122
Name Phone: Office # Mobile #
4760 Richmond Road Ste 200 4760 Richmond Road Ste 200
Current Mailing Address
Cleveland Ohio
City
10. Deed Book No.1005
1005
Current Street Address
44128-5979 Cleveland Ohio
State Zip City
Page No.397
345
State
44128-5979
Zip
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).
BV/Weston JT LAND LLC
Company Name
4760 Richmond Road Ste 200
[e-mail]
E-mail Address
4760 Richmond Road Ste 200
Current Mailing Address Current Street Address
Cleveland Ohio 44128-5979 Cleveland Ohio
City State
Phone: Office # 440-349-9000
Zip City
Mobile #
State
44128-5979
Zip
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:
CT Corporation System
Name of Registered Agent
160 Mine Lake Ct. Ste. 200
[e-mail]
E-mail Address
160 Mine Lake Ct. Ste. 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office # 440-349-9000 Mobile #
James A. Asher
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
Phone: Office #
State
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
James A. Asher
Type or print name
President
Title or Authority
o �a01
Lignat a Date
I, Sfig_\)eta sp)'� 6 , a Notary Public of the County of C L. ,JA �a��
O\\110
State ofNofth Uam ifra. hereby certify that :S +Mt-5 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 1 Leh day of 20 'c)�
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STEVEN SPTTHAS
= :•; -
NOTARY PUBLIC
STATE OF OHIO
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Reoorded in
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= Cuyahoga County
My Comm.Exp.11R612023
Notary
My commission expires 11 ] a, 6 aba•?�

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:
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 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 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.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail 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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip