NCC215378_FRO Submitted_20210930

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. Abzena mAb Facility
1. Project Name
2. Location of land -disturbing activity: County Lee City or Township Sanford
Highway/Street
6075 Enterprise Park Drive Latitude 35.5609Longitude -79.1577
3. Approximate date land -disturbing activity will commence -August 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.00 Acres
6 Amount of fee enclosed: $1,260.00 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example; 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been fled? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Alexander Jenkins E-mail Address [e-mail]
Telephone [phone] Cell # 919-417-6672 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Abzena (North Carolina) LLC [phone]
Name Telephone Fax Number
360 George Patterson Blvd 360 George Patterson Blvd
Current Mailing Address Current Street Address
Bristol, PA 19007 Bristol, PA 19007
City State Zip City State Zip
10. ❑eed Book No. 1640 Page No. 846 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.) lithe company orfrrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Abzena (North Carolina) LLC [e-mail]
Name
360 George Patterson Blvd
Current Mailing Address
Bristol, PA 19007
E-mail Address
360 George Patterson Blvd
Current Street Address
Bristol, PA 19007
City
State Zip City
Telephone [phone] Fax Numbe
State
Zip

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:
CT Corporation System
Name
E-mail Address
160 Mine Lake Ct, Suite 200 160 Mine Lake Ct, Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27615
Raleigh, NC 27615
City State Zip City State Zip
Telephone 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.,
NIA
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone
Fax Number
(c) In 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:
CE Group, Inc.
Engineering Firm or other consultant
Jacob Hudson, PE
[e-mail]
E-mail Address
919-367-8790 ext.110 NIA
Individual contact person (type or print) Telephone
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.
ti (LA(( CA4_ air COa
Type or print name Title or Authority
Signature Date
a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of 20
S Q' c ��yy--�� �'cL"'O 0-4 tic) tz- y C. — 4� A-C.-
Seal Notary 1prl�', .�tLl� Ito �a
My commission expires

CALIFORNIA CERTIFICATE OF ACKNOWLEDGMENT
A notary
pubIic or other officer completing this certificate verifies only the identity of
the individual who signed the document to which this certificate is attached, and not
the truthfulness, accuracy, or validity of that document.
State of California
County of San Diego
On September Ist 2021 beforeme, Pranathi Komandla, Notary Public
(here Insert name and title of the officer)
personally appeared r'
who proved to me on the basis of satisfactory evidence to be the person whose name,W is/aW subscribed to
the within instrument and acknowledged to me that )Wshe/th f executed the same in �+s -rer/Oyv r
authorized capacity(ies-�, and that by his/her/tWir signature4si on the instrument the persorO, or the entity
upon behalf of which the person(af acted, executed the instrument.
certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature }�
P"NATHI K0NANDLA
COMM 922616M
Notary Public - California
San Diego County Ilt
COMMEx res Get!, 2022
(Seal)
Optional Information
Although the information in this section Is not required by law, it could prevent fraudulent removal and reattachment of this acknowedgment to an
unauthorized document and may prove useful to persons relying on the attached document.
Description of Attached Document
Additional Information
The preceding Certificate Acknowledgment is attached to a document Method of Signer Identification
titled/For the purpose of �+��r�e �� y tt Proved to me on the basis of satisfactory evidence:
Q form(s) of Identification (D credible witness(es)
Ali !t4 A -• Y u
—"--- Notarial event is detailed in notary journal on:
containing Z pages, and dated Page tZt Page# Entry#
The signer(s) capacity or authority is/are as:
❑ Individual(s)
❑ Artomey-in-Fact
El Corporate Officer(s)
Notary contact:
Other
❑Additional Signer(s) Slgner(s)Thumbprint(s)
7ltleisl
❑
❑ Guardian/Conservator
❑ Partner - Limited/General
❑ Trustee(s)
❑ Other:
representing:
Namets) or Personas) or Enllty(les) Signer Is Representing
0 Copyright 2007.2016 Notary Rotary, Inc PO Box 41400, Des Moines, IA 503 r 1.0507. All Rights Reserved. Item Number 101772 Please contact your Authorized Reseller to purchase cop9es of this form"

CALIFORNIA CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity of
the individual who signed the document to which this certificate is attached, and not
the truthfulness, accuracy, or validity of that document.
State of California
County of San Diego
on September 2021 before me, Pranathi Komandla, Notary Public
{here insert name and title of the officer)
personally appeared
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature
Optional Information
(Seal)
Although the information in this section is not required by law t could prevent fraudu'ent removal and reattachment of this acknowledgment to an
unauthorized document and may prove usefu: to persons re ying on the attached document.
Description of Attached Document
The preceding Certificate of Acknowledgment is attached to a document
titled/for the purpose of
containing pages, and dated
The signer(s) capacity or authority is/are as:
❑ Individual(s)
❑ Attorney -in -Fact
❑ Corporate Officer(s)
Tillers)
❑ Guardian/conservator
❑ Partner - Limited/General
❑ Trustee(s)
❑ Other:
representing:
Name(s) of Person(s) or Entlty(ies) Signer Is Representing
Method of Signer Identification
Proved to me on the basis of satisfactory evidence:
O form(s) of identification i] credible witness(es)
Notarial event is detailed In notary journal on:
Page # Entry #
Notary contact:
Other
❑ Additional Signer(s) ❑ Signer(s)Thumbprints)
C copyright 2007.2016 Notary Notary. Inc. PO Boa 41400, Des Moines, to 50311.0507 All Rights Reserved. Item Number 101772 Please contact your Authorized Reseller to purchase copies of this form.