NCC216306_FRO Submitted_20211112

JOHNSTON COUNTY 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
Johnston County Department of Public Utilities. (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.
1. Project Name Benson Global, LLC
2. Location of land -disturbing activity: City or Township Benson
Highway/Street 1203 Chicopee Rd Latitude 35.36582 Longitude -78.55724
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 34.4
6. Amount of fee enclosed: $ 6925.00 . The application fee of $380.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $125 per acre for each
additional acre (rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dale Parker E-mail Address [e-mail]
Telephone Cell # 919-820-0425 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Chicopee, INC
Name Telephone
PO Box 959
Current Mailing Address
Evansville NC 47706
City State Zip
10. Deed Book No, 1432
Part B.
Current Street Address
City
Page No. 692
State
Fax Number
0
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Dale Parker [e-mail]
Name E-mail Address
PO Box 565 130 Corporate Parkway
Current Mailing Address Current Street Address
Benson NC 27504 Benson NC 27504
City State
Telephone [phone]
Zip City
Fax Number
State
E

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:
Name
E-mail Address
Current Mailing Address
Current Street Address
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:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
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.
Dale Parker
Type or print na e
Signature
Title or Authority
Date
le-(k';k /
I, JO m I L h) I(WA , a Notary Public of the County of T) )
State of North Carolina, hereby certify that :1) (1 C''P�_Y Y 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 1�+h day of 20(-9_
_r-�Off-A 'L. 4�bllamd
JAMIE HOLLAND Not r
tWelry Public, North Caroline
Harnett County M commission expires
j
My Commission Expires y p I I�
December 14, 2021