NCC231901_FRO Submitted_20230620

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 NCG01 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 Weyerhauser Ayden CDK
-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 Pitt City or Township Grifton
SR 1949 Hanrahan Road 35.4134 -77.4197
Highway/Street 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.):Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):5.7 Acres
6. Amount of fee enclosed: $600 . 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 m No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jack Godwin E-mail [e-mail]
Phone: Office# 252-746-7217 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Weyerhaeuser NR Company 252-746-7268 928-581-9314
Name Phone: Office# Mobile#
PO Box 280 371 East Hanrahan Road
Current Mailing Address Current Street Address
Ayden NC 28513 Grifton NC 28530
City State Zip City State Zip
10. Deed Book No.2574 Page No.827 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 party(ies).
Weyerhaeuser NR Company [e-mail]
Company Name E-mail Address
PO Box 280 371 East Hanrahan road
Current Mailing Address Current Street Address
Ayden, NC 28513 Grifton NC 28530
City State Zip City State Zip
Phone: Office# 252-746-7268 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:
Jerry Nix [e-mail]
Name of Registered Agent E-mail Address
200 Occidental Avenue South 200 Occidental Avenue South
Current Mailing Address Current Street Address
Seattle, WA 98104 Seattle, Washington 98104
City State Zip City State Zip
Phone: Office# 252-746-7268 Mobile# [phone]
Bryan Ulrich
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.
Bryan Ulrich Plant Manager
Type or print name Title or Authority
Signature Date
I, �i C.kNZ , a Notary Public of the County of tke-s-bi,„4
State of North Carolina, hereby certify that ArrA u fr,•'ck_ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
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