NCC221929_FRO Submitted_20220523

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 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, {dace NIA in the blank.)
Part A.
1. Project Name Concrete Supply Co.., L.L.C. Site Flan
2. Location of land -disturbing activity: County°��t u�s�� City or TovvnshipTOwn (7fi Selma
Highway/Street SR 1929 - West Oak Street 35.5533 _78.3157
Latltudefaecimal tlegreas} Longltude(deamal tlegrea,)
3. Approximate state land -disturbing activity will commence: Upon receipt ®f permit
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Cemmerclal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7. 37
6. Amount of fee enclosed: $800.00 . 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 p No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Briar Webb E-mail [e-mail]
Phone: Office # [phone] lUlobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Concrete SUPPly Co., L.L.C. [phone] [phone]
Name Phone: Office # Mobile #
P.O. Box 5247 3323 Raleigh Street
Current Bailing Address Current Street Address
Charlotte NC 28299 Charlotte NC 28206
City State Zip City State Zip
10. Deed Book No.06121 Page No.0453 provide a copy of the mast 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.) It the campanyis a sole proprietorship orif the landowner(s) is
an individuals), the names) of the owner(s) may be listed as the financially responsible party(ies).
Concrete Supply Co., L.L.C. [e-mail]
Company Name E-mail Address
P.O. Box 5247 3823 Raleigh Street
Current Mail±ng Address Current Street Address
Charbtte NC 28299 Charlotte PAC 28206
City State Zip City State Lip
Phone: Office # [phone] Mobile # [phone]
Note: J 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:
NIA N/A
Name of Registered Agent E-mail Address
NIA NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
Phone: Office # NIA Mobile # NIA
NIA
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:
NIA NIA
Name of Registered Agent E-mail Address
g
NIA I /A
Current Mailing Address Current Street Address
NIA N/A
City State Zip City State Zip
Phone: Office # NIA Mobile # N/A
N/A
N�.ima of Individual to Contact (if Registered Agent is a company)

(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.
N/A
Company DBA Narne
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.
Type or print/name Title or Authority
2-z2 Z�
Date
a Notary Public of the County of r
State of North Carolina, hereby certify that, appeared personally
before me this day and being duly sworn acknowledgea that the above form was executed by him/her.
Witness my hand and notarial seal, this "Oa day of V'�-Io20
j � h P
e a
No ry
My commission expires i 17, F'O.-.
Jennifer R Sm th
NOTARY PUBLIC
catbaffus County
North Carolina
My CornmisWn Expires October 18, 2025