NCC222997_FRO Submitted_20220823

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Westwinds Production Faci
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street West Winds Blvd. Latltude(decimal degrees) 35.3895 Longltude(decimal degrees)-80.7809
3. Approximate date land -disturbing activity will commence: August 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 10.7
6. Amount of fee enclosed: $ 1,100.00 . 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 L� No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Thom LaClaire E-mail Address tlaclaire .nascar.com
Phone: Office # 386-681-6494 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Westwinds Center, LLC 386-681-6847
Name Phone: Office # Mobile #
1 Daytona Blvd.
Current Mailing Address
Daytona Beach, FL 32114
City State Zip
10. Deed Book No. 12379 Page No.
1 Daytona Blvd.
Current Street Address
Daytona Beach, FL 32114
City State Zip
313 Provide a copy of the most 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.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Westwinds Center, LLC
Company Name
1 Daytona Blvd.
Current Mailing Address
Daytona Beach, FL 32114
City State Zip
Phone: Office # 386-681-6847
[e-mail]
E-mail Address
1 Daytona Blvd.
Current Street Address
Daytona Beach, FL 32114
City
Mobile #
State Zip
913-526-5897
Note: If 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:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
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
Corporation Service Company
Name of Registered Agent
2626 Glenwood Ave. Suite 550
Current Mailing Address
Raleigh,
City
NC 27608
State Zip
Phone: Office # 800-927-9800
Jeff Boerger
[e-mail]
E-mail Address
2626 Glenwood Ave. Suite 550
Current Street Address
Raleigh, NC 27608
City
Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
Company DBA Name
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.
Jeffrey T. Boerger
Tvpe,or print
Vice President
Title or Authority
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Date
14Prn r, a Notary Public of the County of ���i� ,�; c
State of Florida, hereby certify that j e, -W r -e� / appeared personally before
me this day and being duly sworn acknowledged that the above orm was executed by him/her.
Witness my hand and notarial seal, this _day of
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