NCC215468_FRO Submitted_20211005

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 a -mail andlor
fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Nestle Purina Garden Keeper
rJ
3
Location of land -disturbing activity: County Rockingham
Highway/StreetEast Meadow Road Latitude36,521506
City or Township Eden
Approximate date land -disturbing activity will commence: 6/1 /2 02 1
Longitude-7g'71614
4. Purpose of development (residential, commercial, industrial; institutional, etc.}: I nd ustria1
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 27
6. Amount of fee enclosed. $ 8755 . 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 filed? Yes No X Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Billy Thomas E-mail Address [e-mail]
Telephone $59-629-2197 Cell # 859-629-2197 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Nestle' Purina PetCare Company 314-982-1000 314-982-3698
Name
1 Checkerboard Square
Current Mailing Address
St. Louis, MO, 63134-0001
Telephone
Current Street Address
Fax Number
City State Zip City State Zip
10. Deed Book No. 1586 Page No. 2560 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 he listed as the financially responsible party.
Nestle' Purina PetCare Company
Name E-mail Address
1 Checkerboard Square
Current Mailing Address Current Street Address
St. Louis, MG, 63134-0001
City State Zip
Telephone [phone]
City State Zip
Fax Number 314-982-3698

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:
1=1 Z
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
state Zip 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:
CT Corporation System
Name of Registered Agent
160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh, NC 27615
City
State Zip
Telephone [phone]
E-mail Address
Current Street Address
City State Zip
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.
Dyer and Associates
Engineering Firm or other consultant
Bryan Dyer
Individual contact person (type or print)
[e-mail]
E-mail Address
[phone]
'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.
Type or print name Title or Authority
M
Signature
5/-5a I
Date
c,ty
-,a Notary Public of thef ettntq of
,ILI r SS L'i.J�r
State of , hereby certify that H el �'eF • 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 , r`� day of Mc. 4 , 20�" -i
Notary
Seal
Maureen L. Elbert My commission expires %+'}T�,�
Notary Public - Notary Seal
STATE OF MISSOURI
St. Louis City
My Commission Expires: May 28, 2022
Commission #14434424