NCC233568_FRO Submitted_20231218

;heck 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. Proiect Name Research Triangle Logistics Park
*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).
Water and Sewer Extensions
Orange Hillsborough
2. Location of land-disturbing activity: County City or Township g
36.037186 -79.102926
Diversity Drive
Highway/Street _._. ...__._.,� Latltude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:July 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Industrial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 8
6. Amount of fee enclosed: $800 . 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 x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Don Sever E-mail Address [e-mail]
Phone: office# 919 322 0115 x3239 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Terra Equity I,LLC-Corporation Service Company n/a n/a
Name Phone: Office# Mobile#
2626 Glenwood Ave., S 550 2626 Glenwood Ave., S 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
10. Deed Book No.6822 Page No.969-977 Provide a copy of the most current deed.
6823 2117-2119

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).
Barrister Construction Corp [e-mail]
Company Name E-mail Address
3810 Springhurst Blvd S 120 3810 Springhurst Blvd S 120
Current Mailing Address Current Street Address
Louisville KY 40241 Louisville KY 40241
City State Zip City State Zip
Phone: Office# 502-412-2800 Mobile# n/a
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:
Terra Equ ; LLC-Corporation Service Company Short& - - ingfulton.com
Name of Register-• ' s ent E-m-' - •dress
2626 Glenwood A ► S 550 626 Glenwood Ave., S 550
Current Mailing Address Current Street Address
Raleigh NC 27608 ' - eigh NC 27608
City -te Zip City State Zip
Phone: Offi = 19 787 8880 Mobile# n/a
Doti! hort
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:
ik\e4'S)‘--414n-
Nam Registered Age E-mail Address
Current Mailing Address Current Street Address
NC_ 21ifilo�
City State Zip City State Zip
Phone: Office# `'o 1 - -fw- wg 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 aut rfty.,to execute instruments for the Financially Responsible Party). I agree to provide
corr ed information should there be any change in the information provided herein.
Typ o ame Title or Authority
&-CA-2ty
igmatu Date
I, ?o.*c\L . L . '1 460rvt.....- , a Notary Public of the County of �
6#32),2&____
State of Ne l ,hereby certify that `FJt-�`C.- ifIc C 'a 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 CT$ day of j cc S+" , 20 2.3
Notary
My commission expires ;kit( /a, a'
.Jay wi›.: KyN /l,1 P 71