NCC230364_FRO Submitted_20230213

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, place N/A in the blank.)
Part A.
1. Project Name Mt. alive Pickle
2. Location of land -disturbing activity: County Wayne City or Township Goldsboro
Highway/Street W Ash 5t 35.391461-78.015801
Latitude(decdmal degrees) Longitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: December, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.45
6. Amount of fee enclosed: $ 500 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lucas Waller E-mail [e-mail]
Phone: office # 919-658-2535 Ext 3202 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mount alive Pickle Company 919-581-3612
Name
Pa Box 609
Current Mailing Address
Mount alive, NC 28365
City State
10. Deed Book No. 3650
Phone: Office #
1 Cucumber Blvd
Mobile #
Current Street Address
Mount alive, NC 28365
Zip City
Page No. 883
State
911-1
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 individuals), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Mount Olive Pickle Company
Company Name
PO Box 609
Current Mailing Address
Mount Olive, NC 28365
City State
Phone: office # 919-581-3612
[e-mail]
E-mail Address
1 Cucumber Boulevard
Current Street Address
Mount Olive, NC 28365
Zip City
Mobile #
State
W,
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
William H. Bryan
[e-mail]
Name of Registered Agent
E-mail Address
PO Box 609
1 Cucumber Blvd
Current Mailing Address
Current Street Address
Mt Olive NC 28365
Mt Olive NC 28365
City State
Zip City State Zip
Phone: office # 919-581-3610
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:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
city State
zip city State zip
Phone: Office #
Mobile #
Name 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.
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.
Richard D. Bowen
Typ or print ame
�w
Signature
Executive VP/CFO
Title or Authority
10/31 /22
Date
I, n VV I L i ' a a Notary Public of the County of a vic-
State of North Carolina, hereby certify that !` ' C'1'1_2 VC1 W appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this '�) I� day of r , 205 G--
-1 A R Notary
P U 60G My commission expires
Alt r rri>>