NCC216944_FRO Submitted_20211228

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. Macy Grove
1. Project name
6
3.
4.
5.
6
Location of land -disturbing activity: County Guilford City or Township Kernersville
Highway/Street HWY 421 Latitude36.104303 Longitude-80.039370
Approximate date land -disturbing activity will commence December 2021
Purpose of development (residential, commercial, industrial, institutional, etc.). Industrial
Total acreage disturbed or uncovered (including off -site borrow and waste areas). 145
Amount of fee enclosed. 5 9425 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Caleb Moore E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
(See Attached Sheets)
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No Page No. 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.
NP Piedmont Commerce Center, LLC
Name E-mail Address
4825 NW 41 st Street, Suite 500
Current Mailing Address Current Street Address
Riverside, MO 64150
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:
Karen Rozar c/o CT Corporation System [e-mail]
Name
160 Mine Lake CT, Suite 200
Current Mailing Address
Raleigh, NC 27615
City State
Telephone [phone]
E-mail Address
Current Street Address
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
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.
Manager of NPD Management, LLC, the Manager of NP Piedmont Commerce Center
Nathaniel Hagedorn JV,LLC, the Sole Member of NP Piedmont Commerce Center, LLC
Type or print name
igriature
&81'anrtolina,
I
State of he eby
personally before me this day
executed by him.
Title or Authority
Date
, a Notary Public of the County of LL ' C.
certify that appeared
and being duly sworn acknowledfod that the above form was
Witness my hand and notarial seal, thiJoday of 20r
Notary
Seal
LISA L BEASLEY
y commission expires 1
Notary Public - Notary Seal
Platte County - State of Misso]20233
Commission Number 194975
My Commission Expires Sep 10,