NCC230628_FRO Submitted_20230309

JOHNSTON COUNTY 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
Johnston County Department of Public Utilities. (Please type or print and, if the question is not applicable or
the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Merritt 42 - Crossing
2. Location of land -disturbing activity: City or Township Garner (Johnston County)
Highway/Street NC Hwy 42 Latitude 35.6011 Longitude-78.5788
3. Approximate date land -disturbing activity will commence: September 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 21.5
6. Amount of fee enclosed: $ 5,300 . The application fee of $380.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $125 per acre for each
additional acre (rounded up to the next acre), Individual residential lots plans are $100 per lot.
7. Has an erosion and sediment control plan been filed? Yes ❑ No ❑ Enclosed_121
_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nate Robb E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Merritt-NCFT1, LLC
919.526.0070
Name
Telephone Fax Number
2066 Lord Baltimore Drive
2066 Lord Balltimore Drive
Current Mailing Address
Current Street Address
Baltimore MD
21244 Baltimore MD 21244
City State
Zip City State Zip
10. Deed Book No, 06304
Page No, 224-230
Part B.
1. Person(s) or firm(s) who are
financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible
parties on an attached sheet):
Merritt-NCFT1, LLC
[e-mail]
Name
E-mail Address
2066 Lord Baltimore Drive
2066 Lord Baltimore Drive
Current Mailing Address
Current Street Address
Qaltimore MD
21244 Baltimore MD 21244
City State Zip
Telephone [phone]
City
Fax Number
State
Zip

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:
Clifton Keith Wallace , Merritt-NCFT1, LLC
[e-mail]
Name
E-mail Address
1 TW Alexander Drive, Suite 115
1 TW Alexander Drive, Suite 115
Current Mailing Address
Current Street Address
Durham NC 27703
Durham NC 27703
City State Zip
City State Zip
Telephone [phone]
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
Telephone
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.
Clifton Keith Wallace
Typ r rint name
Sig atu
Registered Agent 1 Vice President
Title or Authority.
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Date
I, finny N (a) lahao , a Notary Public of the County of
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State of North Carolina, hereby certify that C lif-tv" IGe;-f? Wall ace appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
C
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Seal
My Comm. Exp.
06-22.2025
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My commission expires J 1i e 211207,5

Additional List of Property owners
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Triple B #32-Mast, LLC. 252.353.2141
Name Telephone Fax Number
530 SE Greenville Blvd, Suite 200 530 SE Greenville Blvd, Suite 200
Current Mailing Address Current Street Address
Greenville NC 27858-6759 Greenville NC 27858-6759
City State Zip City State Zip
10. Deed Book No. 06244 page No. 0253-0255