NCC216583_FRO Submitted_20211214

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. Riveroaks BuildingE
1. Project Name.
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street 8500 Automation Drive Latitude 35 24'19" _ Longitude.80 42' 44"
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):2.0
6. Amount of fee enclosed: $ 130.00 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Joe Thompson E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Exeter 8500 Automation, LLC 407-748-6888
Name Telephone Fax Number
101 W. Elm St., Suite 600
Current Mailing Address Current Street Address
Conshohocken, PA 19428
City State Zip City State Zip
10. Deed Book No._13098 Page No. 0207 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.
Exeter 8500 Automation, LLC [e-mail]
Name E-mail Address
101 W. Elm St., Suite 600
Current Mailing Address
Conshohocken, PA 19428
City State
Current Street Address
Zip City State
Telephone [phone] Fax Number
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:
Corporation Service Company
Name
2626 Glenwood Ave., Suite 550
Current Mailing Address
Raleigh, NC 27608
City State Zip
Telepho
E-mail Address
Current Street Address
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:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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 rovided herein.
Jason Honesty GOM
Type or print name Title or Authority
o�� —2•
Sign re Date
-------------------------
1, a Notary Public of the County of �•�tv�ca.��-r
pa...lZ�r�vw�vd
State of a, hereby certify that _ G1Cy 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
WAR
Commonwealth of Pennsylvama • Notary Seal L� Lisa Bianchini, NotEkry Public
Montgomery County
ommission expires November25, 2022 ry
E I Commission number 1011466 �� �� Member, Pennsylvania Association ofNctarles My commission ex Tres` ��'