NCC231695_FRO Submitted_20230602

Check if this project is ARPA-funded
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT(APRIL 2023)
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 City of
Archdale ACE Integrated Stormwater Management Program Submit the completed form and current deed to
the appropriate personnel (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_ Axium
'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 Randolph City or Township Trinity
Highway/Street Eden Terrace Latitude(decimal degrees) 35.9153 LongitUde(decimaldegrees) -79.958
3 Approximate date land-disturbing activity will commence June 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc,) Industrial
5 Total acreage disturbed or uncovered (including off-site borrow and waste areas): 22.0
6. Amount of fee enclosed. $ 2,765 The application fee is defined in the published City
of Archdale fee structure which is typically$0 when a Technical Review Committee (TRC)evaluation is
required. Checks should be addressed to City of Archdale
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed Z No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Channing Chrismon E-mail Address [e-mail]
Phone: Office# 336-784-2000 Mobile#
9. Landowner(s) of Record(attach accompanied page to list additional owners)
PJP Holdings LLC 614-822-9980
Name Phone: Office# Mobile#
9005 Smiths Mill Road
Current Mailing Address Current Street Address
New Albany, OH 43054
City State Zip City State Zip
10. Deed Book No. 2847 _Page No. 1221 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)maybe listed as the financially responsible parly(ies)
PJP HOLDINGS LLC vbhindwallarn axiumplastics.com
Company Name E-mail Address
9005 Smiths Mill Road
Current Mailing Address Current Street Address
New Albany, OH 43054
City State Zip City State Zip
Phone: Office# 614-706-5955 Mobile#
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:
CT Corporation Systems privacy redaction
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# 609-716-0300 Mobile#
J Michele Balnius
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:
Engineering firm or other consultant E-mail Address
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.
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Type or print name l Title or Authority
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Signature Date
1p/
I 1 Y\Q, 164S1(4 6 . a Notary Public of the County of L..1 C 1n
State of North Carolina, hereby certify that U eNo. .k\ \ \a,\1a,1("('appeared personally
before me this day and being duly sworn acknowledged that/ the above form was executed by him/her
3
Witness my hand and notarial seal, this l day of /v `LA: , 20 3
V\OLAq-Q-0
=�'r �����` Katherine Riley Patsiavos
=k�= -� �.- Notary Public,State of ohlo Notary
':a '.;� My Commission Expires 02.20.28
y; �`° My commission expires � —�v—� Oa