NCC231355_FRO Submitted_20230509

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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 Mid-State Parcel Grading
2. Location of land-disturbing activity: County Chatham City or Township Slier City
Highway/Street Bish Road 35.7492 -79.5060
Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:April 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Future Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 30
6. Amount of fee enclosed 5000
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 52,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Hall tC
S
bhall ameor
E-mail Address [e-mail]
Phone: office# 336-544-2600 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Toddy & Veronica Brooks 919-930-4768
Name Phone: Office# Mobile#
1112 Stockyard Road
Current Mailing Address Current Street Address
Staley NC 27355
City State Zip City State Zip
Page No. 0679 10. Deed Book No. 0711 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).
Mid-State Development Center, LLC [e-mail]
Company Name E-mail Address
4319 Waterleaf Court
Current Mailing Address Current Street Address
Greensboro NC 27410
City State Zip City State Zip
Phone: Office# Mobile# [phone]
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:
Kirk J Bradley kbradley©Imoc.net
Name of Registered Agent E-mail Address
603 Carthage Street, Suite 120
Current Mailing Address Current Street Address
Sanford NC 27330
City State Zip City State Zip
Phone: Office#919-895-6001
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
(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:
CE Group, Inc jeff©cegroupinc.com
Engineering firm or other consultant E-mail Address
Jeff Foster, PE 919-367-8790 x-105 828-545-2972
Individual contact person (type or print) 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.
Peter Timothy Booras Manager
Typ r rint name Title or Authority
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1, S CLA w Ll.cw , a Notary Public of the County of G� � CA
State of North Carolina, hereby certify that a4--C't'Tlwt-DfLy 000vas 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 Z day ofPS-1)1/1.
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Mid-State Development Center, LLC
Name Phone: Office# Mobile#
4319 Waterleaf Court
Current Mailing Address Current Street Address
Greensboro NC 27410
City State Zip City State Zip
Deed Book No.2336 Page No. 0920 _Provide a copy of the most current deed.
Landowner 3 of Record:
Mid-State Development Center, LLC
Name Phone: Office# Mobile#
4319 Waterleaf Court
Current Mailing Address Current Street Address
Greensboro NC 27410
City State Zip City State Zip
Deed Book No.2336 Page No. 1014 Provide a copy of the most current deed.
Landowner 4 of Record:
Mid-State Development Center, LLC
Name Phone: Office# Mobile#
4319 Waterleaf Court
Current Mailing Address Current Street Address
Greensboro NC 27410
City State Zip City State Zip
Deed Book No.2336 Page No. 1018 Provide a copy of the most current deed.
Landowner 5 of Record:
Mid-State Development Center, LLC
Name Phone: Office# Mobile#
4319 Waterleaf Court
Current Mailing Address Current Street Address
Greensboro NC 27410
City State Zip City State Zip
Deed Book No.2338 Page No. 0411 Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#