NCC222789_FRO Submitted_20220812

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name CARGILL-- PROJECT WOLFPACK
2. Location of land -disturbing activity: County CUMBERLAND City or Township EASTOVER TWNSHP
Highway/Street 1754 RIVER ROAD Latitude 35 DEG 05' 16" Longitude 78 DEG 50' 52"
3. Approximate date land -disturbing activity will commence: JUL 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):INDUSTRIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):2.1 AC
6. Amount of fee enclosed: $195. 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 JODY ANDERSON, CARGILL PM E-mail Address: [e-mail]
Telephone [phone] Cell # 507-276-8577 Fax # None
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CARGILL, INC. 952-742-7575 952-742-7393
Name Telephone Fax Number
PO BOX 5626 15407 MCGINTY ROADWAY WEST
Current Mailing Address Current Street Address
MINNEAPOLIS MN 55440 WAYZATA MN 55391
City State Zip City State Zip
10. Deed Book No. 10084 Page No. 0374 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):
CARGILL, INC (JACOB ZOSS, PLANT MANAGER) JACOB ZOSS(cDCARGILL.COM
Name E-mail Address
1754 RIVER ROAD SAME
Current Mailing Address Current Street Address
FAYETTEVILLE NC 28312 SAME
City State Zip City State Zip
Telephone [phone] Fax Number 910-433-4926

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
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
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!
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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 atto m ey-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.
JACOB ZOSS
Type or print name
Signdture
CARGILL FAYETTEVILLE PLANT MANAGER
Title or Authority
H 12-
Date
I, 14rltIa WVA; +i -,a Notary Public of the County of C IAmber 1 Q.n8
State of North Carolina, hereby certify that --:S-c3C O)3 zb3S 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 2C' day of Apri k , 20?-1
Seal
arw� _U_��
Notary
My commission expires /42_JO_OO9'q