Revised FRO Form_Signed

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. 1. Project Name -Carolina Sunrock LLC - Burlington North
2.
3
Location of land -disturbing activity: County Caswell City or Township Anderson
Highway/Street NC Hwy 62 Latitude 36.247842° Longitude-79.3278630
Approximate date land -disturbing activity will commence- Spring 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Asphalt Plant Facility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 24.0 AC
6. Amount of fee enclosed: $ $1,560 . 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 Scott Martino E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Caswell Properties LLC (919)-747-6400 [phone]
Name Telephone Fax Number
200 Horizon Drive Suite 100 200 Horizon Drive Suite 100
Current Mailing Address
Raleigh, NC 27615
City State
10. Deed Book No. 579
Current Street Address
Raleigh, NC 27615
Zip City State Zip
Page No. 1231 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 may be listed as the financially responsible party.
Caswell Properties LLC [e-mail]
Name
200 Horizon Drive, Ste. 100
Current Mailing Address
Raleigh, NC 27615
City State Zip
Telephone [phone]
E-mail Address
200 Horizon Drive, Ste. 100
Current Street Address
Raleigh, NC 27615
City State
Fax Number [phone]
Zip

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:
Gregg Bowler EVP Chief Operating Officer & Chief Financial Officer
Name of Registered Agent
200 Horizon Drive Suite 100
Current Mailing Address
Raleigh, NC 27615
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
200 Horizon Drive Suite 100
Current Street Address
Raleigh, NC 27615
City State Zip
Fax Number [phone]
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.
Gregg Bowler
EVP Chief Operating Officer & Chief Financial Officer
Type or ' ame Title or Authority
06-01-2020
Sig ature Date
I, sFLr 'Q, rfjOC.��Anf, a Notary Public of the County of
WO.ke
State of North Carolina, hereby certify that re-00 �6 W iR r 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
JEFFERY R COCKMAN JR
Notary Public, North Carolina
Wake County
M si E - es
3- day of SUh F_ , 20 a b
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Nota
My commission expires ►o A 9 la0 a �