NCC241019_FRO Submitted_20240405

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM HENDERD
HENDERSotl_allDN
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 Henderson County Site Development Department. (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.)
Sign the original form in BLUE INK.
Part A.
1. Project Name Kyocera Expansion
2. Location of land-disturbing activity: County Henderson City N/A
Highway/Street 100 Industrial Park RD Latitude N35.3686 Longitude W82.4853
Property Identification Number(s) PIN's 9660-17-3156
3. Approximate date land-disturbing activity will commence: March 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.50
6. Amount of fee enclosed: $600•00 . The application fee of$300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac=$2,900.00).
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 Patrick Wood E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kyocera International, Inc 858-576-2602
Name Telephone
8611 Balboa Avenue same
Current Mailing Address Current Street Address
San Diego CA 92123 same
City State Zip City State Zip
10. Deed Book No. 519 Page No.249 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 maybe listed as the financially responsible party.
Kyocera International, Inc [e-mail]
Name E-mail Address
8611 Balboa Avenue same
Current Mailing Address Current Street Address
San Diego CA 92123 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:
Corporation Service Company
Name E-mail Address
2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh NC z�a
City State Zip City State Zip
Telephone
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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.
Theodore Engebretson Vice President
Type or print name Title or Authority
0. ,''2 9
Signature Date
, a Notary Public of the Count
State of , hereby certify that
appeared personally before me this day and bein ,dtriji sworn acknowledged that the above
form was executed by him.
Witness my hand and notarial sea s day of , 20
C;\c -�� Notary
Seal P\a02�
My commission expires
e•

CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document.
State of California
•
County of SCE �1g3()On 1 ,1CI ajy �r-J before me, A[ieca Shr.010 ✓1 Pif(c-
Date �/ r Here Insert Name and Title of the Officer
f
personally appeared 1 < ecdt Y� £r) e L re't-Sc)rl
lame(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies),and that by his/her/their signature(s)on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
-- is true and correct.
. � ALICIA SHERIDAN
c � COMM. #2341766 z� WITNESS my hand and official seal.
ce,�: L. Notary Public•California A
_ San Diego County •
Mx Comm.Expires Jan_16,2025� 7441
- Signature GCe�a' a—v-----
Signature of Notary Public
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: !`i nanCt a/ Wei-et/et c j b;I!fy/(a/Ver-5h s fa re)(n1
Document Date: ,3/24/Zoe Sf / / Number of Pages: Z-
Signer(s) Other Than Named Above: Iv/
Capacity(ies) Claimed by Signer(s)
Sig9er's Name: iheade{e 155ebrel�vt Signer's Name:
R'Corporate Officer — Title(s): V.P. ❑Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑General ❑ Partner — ❑ Limited ❑General
❑ Individual ❑Attorney in Fact ❑ Individual ❑Attorney in Fact
❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator
❑Other: ❑ Other:
Signer Is Representing: Ey arra 1 n kMuNtinall 14(. Signer Is Representing:
©2016 National Notary Association •www.NationalNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907