NCC216966_FRO Submitted_20211217

NC Department of
Environmental Quality
Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM AUG o 2021
SEDIMENTATION POLLUTION CONTROL ACT Winston-Salem
No person may initiate any land -disturbing activity on one or more acres as covered by the Act be&ORi940ice
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.
1. Project Name UPS Mebane
2. Location of land -disturbing activity: County Alamance City or Township Mebane
Highway/Street senator Ralph Scott Pkwy Latitude 36.063 Longitude -79.321
3. Approximate date land -disturbing activity will commence: Sept 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 81.5
6. Amount of fee enclosed: $ $5,330 (82x65=$5,330) . 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 Joseph Hunt
E-mail Address [e-mail]
Telephone [phone]
Cell # Fax #
9. Landowner(s) of Record (attach
accompanied page to list additional owners):
BT- OH, LLC
404.828.6000
Name
Telephone Fax Number
55 Glenlake Parkway NE
55 Glenlake Parkway NE
Current Mailing Address
Current Street Address
Atlanta GA
30328-3474 Atlanta GA 30328-3474
City State
Zip City State Zip
10. Deed Book No. 4096
Page No. 0649 & 0653 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.
BT - OH, LLC
[e-mail]
Name
E-mail Address
55 Glenlake Parkway NE
55 Glenlake Parkway NE
Current Mailing Address
Current Street Address
Atlanta GA
30328-3474 Atlanta GA 30328-3474
City State
Zip City State Zip

Telephone [phone]
Fax Number
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
2626 Glenwood Avenue, Suite 550 2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] 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.
Richard D. Bishop
Type or print n
Signature
Assistant Treasurer
Title or Authority
Date
1, I/t'n c& Lr- . /_ u c a Notary Public of the County of Fu /feg
r�, ~
State off arcr11na, hereby certify that R r.liar!� P. 8,rioP 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 2 n=day of 4uaAst 2021
0
Vince K Luc Notary
Seal NOTARY PUBLIC
Fulton County, GEORGIA My commission expires r12,e1Z,,2_`%
My Commission Expires
05/26/2024