NCC215269_FRO Submitted_20210927

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 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Vandelay MSE Wall Access Roads
1. Project Name
K
3.
Location of land -disturbing activity: County Caldwell
Highway/Street 708 Lynhaven Dr. Latitude 35.89750
City or Township Lenoir
Longitude-815481 °
Approximate date land -disturbing activity will commence: April 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9
6. Amount of fee enclosed: $ 585 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Fred Haydt E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Tapaha Dynamics LLC C/O Corp Service CO [phone]
10.
Name
1600 Amphitheater Parkway
Current Mailing Address
Mountain View CA 94043
City
State Zip
Telephone Fax Number
1600 Amphitheater Parkway
Current Street Address
Mountain View CA 94043
City State Zip
Deed Book No. 1625 Page No. 1652
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Tapaha Dynamics, LLC
Name
708 Lynhaven Dr.
Current Mailing Address
Lenoir NC 28645
City
State Zip
E-mail Address
1600 Amphitheater Parkway
Current Street Address
Mountain View CA 94043
City State Zip
Telephone [phone] Fax Number [phone]

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Corporation Service Company
Name E-mail Address
251 Little Falls Drive 251 Little Falls Drive
Current Mailing Address
Wilmington DE 19808
City
State Zip
Telephone [phone]
Current Street Address
Wilmington DE 19808
City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Corporation Service Company
Name of Registered Agent
251 Little Falls Drive
Current Mailing Address
Wilmington DE 19808
City
State Zip
Telephone [phone]
E-mail Address
251 Little Falls Drive
Current Street Address
Wilmington DE 19808
City State Zip
Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
C�� �5����e r �'�► �� 1 �laN\S
Ty r prin name
Signa e
AJ- jdtL)?_<A NC, tO(Z
Title or Authority
Mil 2I , 21a
Date
.,a Notary Public of the County of
State of North Carolina, hereby certify. that �ri5r�`"��Y ��i�fi �^'+ S appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
5� i�Q
Witness my hand and notarial seal, this aday of , 20
ALEKANDER BARKLEY Notary
Seal NWARY Pueuc
CATAWBA COUNTY, NC My commission expires e!