NCC216068_FRO Submitted_20211103

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. North Airport Industrial Park Tract 4
1. Project Name p
2. Location of land -disturbing activity: County Johnston City or Township Smithfield
Highway/Street GUlfstream Street Latitude 35.55450 Longitude-78.37873
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.05
6. Amount of fee enclosed: $ 650.00 . 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 Norwood Thompson E-mail Address [e-mail]
Telephone [phone] cell # 919-740-8009 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Highway 70 QOZB, LLC 919-553-5400
Name Telephone Fax Number
442 1/2 East Main Street 442 1/2 East Main Street
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
10. Deed Book No. 5912 Page No.-"' 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.
Highway 70 QOZB, LLC [e-mail]
Name E-mail Address
442 1/2 East Main Street 442 1/2 East Main Street
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
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:
Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telepho
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 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.
Norwood Thompson
e or print name
Signature
Steven S. Sanderson
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him.
Witness my hand and notarial seal, this
Steven S. Sanderson
Nota$)60Ublic
Wake County, NC
My Commission Expires — 2
6
Managing Member
Title or Authority
9-13-2021
Date
, a Notary Public of the County of Johnston
Norwood Thompson appeared
duly sworn acknowledged that the above form was
13 day of S ptember 2021
Notary
My commission expires 11-3-2022