NCC222984_FRO Submitted_20220824

SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Richmond Investment Associates, LLC Eastern Campus Expansion
2. Location of land -disturbing activity: Count Richmond City or Township Marks Creek
Highway/Street
SR# 1624 County Home Rd LatltUde(decimai degree34.917601-79.674145
/s�) c /� p LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.54 acres
6. Amount of fee enclosed $2)800 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed m No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameLane Harris E-mail Address [e-mail]
Phone: Office # 91 0-895-5910 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Richmond Investment Associates, LLC �?/_^ ,C?� _ 2z�
Name
5 Highland Drive
Current Mailing Address
11 GX i
Phone: Office # Mobile #
5 Highland Drive
Current Street Address
Putnam CT 06260 Putnum CT 06260
City State Zip City State Zip
10. Deed Book No. Bk1392 Pg392 Page No. Bk1931 Pg561 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).
Richmond Investment Associates, LLC
Company Name
5 Highland Drive
Current Mailing Address
Putnam CT 06260
City State Zip
Phone. office # 860-963-1976 ext223
[e-mail]
E-mail Address
5 Highland Drive
Current Street Address
Putnam CT 06260
City
State
Mobile # [phone]
Zip
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 forthe applicantto 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
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office # 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:
Cogency Global Inc [e-mail]
Name of Registered Agent E-mail Address
212 South Tryon Street Suite 1000 212 South Tryon Street Suite 1000
Current Mailing Address Current Street Address
Charlotte, NC 28281 Charlotte, NC 28281
City State y Zip City State Zip
'12 z 3
Phone: Office # d • Mobile # 66 o
rl��, y]
Name of Individual to Contact ('(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
8

of the Certificate of Assumed Name. v
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Zir- 0764-3qq
a G/00 ;�r' .Tnc,
Eng Bering rm or other con ultant 44 c k).t. JJ
Individual contact person (type or print)
pbtG/IQ.i /!tom MC/1 t. 6-Li<</t.'/;_q^ Crime
E-maiPAddress
1630a 916 16(,
Phone: Office # Mobile #
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
Signature
Ma a
Title or AiAhority
(- l�Y 1 -*' z
Date
---------------------------------------'-----------------------------------------------------------1---'----------------
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\�oQ--Af,), a Notary Public of the County of
State of -deli ra, hereby certify that i ii kA PQ A-Q appeared personally
before me this day and being duly sworn acknowledged that the abo form was executed by him/her.
'1' 1 7_14
Witness my hand and notarial seal, this day of 20 o`Z
'CRYSTALEEN MORIN
SeaINOTARY PUBLIC
' STATE OF CONNECTICUT
MY COMM. EXP 12/312024
S
Notary
My commission expires