NCC224004_FRO Submitted_20221205

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Nave Phase 513 Development - Haywood County (White Oak) Landfill
2. Location of land -disturbing activity: County Haywood City or Township NIA
SR 1338 35,664201-82.998243
NighwaylStreet Latitude�deama� degrees) LOngltude[decimaiaegrees}
3. Approximate date land -disturbing activity will commence: 9/12/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): INDUSTRIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.93
6. Amount of fee enclosed $2,900 . 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 $2,900). 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 Derek Bouchard E-mail Address [e-mail]
Phone: Office # N/A Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Haywood County 828-452-6729
Name Phone: Office # Mobile #
215 N Main Street 215 N Main Street
Current Mailing Address Current Street Address
Waynesville NC 28786 Waynesville NC 28786
City State Zip City State Zip
10. (Deed Book No. 424,425,461 page No. 204,513,1036 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 fisted as the financially responsible party(ies).
5antek Environmental of North Carolina, LLC
Company Name
3898 Fines Creek Rd.
Current Mailing Address
Waynesville NC 28785
City State Zip
Phone: Office # [phone]
[e-mail]
E-mail Address
2440 Whitehall Park Dr.
Current Street Address
Charlotte NC 28273
City State Zip
Mobile # NIA
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 System NIA
Name of Registered Agent E-mail Address
160 Mine Lame Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 Raleigh NC 27615-6417
City State Zip City State Zip
Phone: office # [phone] Mobile # NIA
N/A
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:
CT Corporation System N/A
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 Raleigh NC 27615-6417
City State Zip City State Zip
Phone: Office # [phone]
NIA
Mobile # NIA
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 ❑BA 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:
Hodges, Harbin, Newberry & Tribble, Inc. [e-mail]
Engineering firm or other consultant
Individual contact person (type or print)
E-mail Address
[phone]
Phone: Office #
[phone]
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). l agree to provide
corrected information should there b.e any change in the information provided herein.
Shane Wokker
Tvc r ri n
hature
Area President
Title or Authority
4
Date
a Notary Public of the County of
State of North Carolina, hereby certify that dr "O-, [j"E-4- appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by Inimlher,
Witness my hand and notarial seal, this day of , 20 �v2
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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:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
❑eed Book No. Page No. Provide a copy of the most current deed.
Name
Current Mailing Address
City
Deed Book No._
Name
Current Mailing Address
Phone: Office #
Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
❑eed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 9 in Part 8 ❑f the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
E-mail 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: ❑floe #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #