NCC231529_FRO Submitted_20230519

Check if this project is ARPA-funded
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Bosch Lct102 Manufacturing Expansion
'If this project involves American Rescue Plan Act (ARPA) funds. list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Lincoln City or Township LInCOIntOn
Highway/Street Riverview Road L -81.266
atitude(decimaIdegrees)35.430 Longitude(decimaidegrees)
3. Approximate date land-disturbing activity will commence: May 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):40.0
6. Amount of fee enclosed: $8,000 . 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 ci Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael O'Malley E-mail Address Michael_OMalley©graycor.com
Phone: office# [phone] Mobile # [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Robert Bosch Tool Corporation
Name Phone: Office # Mobile #
38000 Hills Tech Drive
Current Mailing Address Current Street Address
Farmington Hills, MI 48331
City State Zip City State Zip
10. Deed Book No. 3217 Page No. 187 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).
Robert Bosch Tool Corporation [e-mail]
Company Name E-mail Address
38000 Hills Tech Drive 1980 Indian Creek Road
Current Mailing Address Current Street Address
Farmington Hills, MI 48331 Lincolnton, NC 28092
City State Zip City State Zip
Phone: office# [phone] 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:
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)
(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.
Pedro Fondevila Plant Manager
Typeorr .rin •aroma—--- Title or Authority
.40
Signature Date
I.bandke Le , a Notary Public of the County of e_CtiCLU3
State of North Carolina, hereby certify that '- VpY eVN: lq 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 ' day of m , 20 g
Danelle L. Legg OtaXad IL. . A.906
NOTARY PUBLIC Notary
Catawba County
North Carolina My commission expires Defer-Hoar a0 O
My Commission Expires December 20,2023 , }

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:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. 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#

BOSCH
07.21.2022 Robert Bosch Tool Corporation
1800 W. Central Rd.
Mount Prospect, IL 60056
www.bosch.us
North Carolina Secretary of State
2 South Salisbury St.
Raleigh, NC 27601-2903
Letter of Signature Authority
To Whom It May Concern,
This letter authorizes Pedro Fondevila to sign on behalf of Robert Bosch Tool
Corporation.
Sincerely,
ia,T,1„/K0
Katina Xouria
Senior Vice President Finance and Administration (PT/FC-NA)
0 BOSCH are Trademarks of Robert Bosch GmbH,Germany