NCC222629_FRO Submitted_20220725

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 ��i��e
number is unavailable, place NIA in the blank.)
Part A. JUN - 8 2022
1. Project Name: Project Blue/ Vinfast US EV Manufacturing Facility
RWC%h Regional Office
2. Location of land -disturbing activity: County Chatham City or Township
Highway/Street: Moncure-Flatwood Road Latitude(decimal degrees) 36.6170 Longitude decimal degrees) -79 0041
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 205 acres
6. Amount of fee enclosed: $20,500. The application fee of $100.00 per acre (rounded up to the next acre)
is assessed without a ceiling amount (Example: 8.10-acre application fee is $900). Checks should be
addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 2) Enclosed L No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Van Anh Nguyen E-mail Address: [e-mail]
Phone: Office #: [phone] Mobile #: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SEE ATTACHED WORD DOCUMENT FOR INFORMATION ON THE PROPERTY OWNER
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State __-zip7 City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
SEE 5 ATTACHED PDF FILES FOR DEED DOCUMENTATION

Part B.
1 Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page ) If the company is a sole propnetorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
VinFast Manufacturing US, LLC
Company Name
12777 W Jefferson Boulevard, Ste A-101
Current Mailing Address
Playa Vista, California 90066
City State Zip
Phone- Office # [phone]
anh [e-mail]
E-mail Address
12777 W. Jefferson Boulevard, Ste A-101
Current Street Address
Playa Vista, California 90066
City State
Mobile # [phone]
Zip
Note: If the Financially Responsible Parry is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity
2. (a) If the Financially Responsible Parry is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
CT Corporation System
Name of Registered Agent
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh, NC 27615
City State Zip
Phone: Office # [phone]
[e-mail]
E-mail Address
160 Mine Lake Court, Suite 200
Current Street Address
Raleigh, NC 27615
City State
Mobile #
Matthew Baca
Name of Individual to Contact (if Registered Agent is a company)
Zip
(b) If the Financially Responsibie Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
Name of Individual to Contact (if Registered Agent is a company)

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to fist all landowners.
Landowner 2 of Record:
Name
Phone. Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record.
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City
Deed Book No._
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No
State Zip City State Zip
Page No. Provide a copy of the most current deed_
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual. General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
H4(f'wa:� ')-L -v
Type r int + Title or Authority
Signature Date
I, , a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her,
Witness my hand and notarial seal, this day of , 20.
46ee aitac12rd California
compliant notarial certificate.
Notary
My commission expires

Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone- Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip

CALIFORNIA
JURAT CERTIFICATE
A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of Los Angeles
Subscribed and sworn to (or affirmed) before me on this day of
20-2�,- by YO
proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
WITNESS MY HAND D OFFICIAL SEAL.
Signature of Notary Pub
T11SfTNA rA N
COMM. #t2264795 z
gNotary Public - Calft is 70
Los Angeles Cm* c
MY Comm. Nov. 24 2022
OPTIONAL INFORMATION
(Notary Seal)
The jumt contained withnt this document is in accordance with California huo. Any ajjidauit subscribed and sworn to before a notary shall use
tlw preceding wording or substantially similar wording pursuant to Civil Code sections 1789 and 8202. A jurat certificate cannot be affixed
to a document sent by mail or otherwise delivered to a notary public, inchrding electronic means, whereby the signer did not
personally appear before the notary public, even if the signer is known by the notary public. The seal and signature cannot be
affixed to a document without the correct notarial wording. As an additional option an afirant can produce an affidavit on the
same document as the notarial certificate wording to eliminate the use of additional documentation.
DESCRIPTION OF ATTACHED DOCIMENT
1t, t Ovt (Title of document) (1,4," ( f-4—
Number of Pages �L (Includmg jurat)
Document Date t.lvtiC�lp ��
(Additional information)
MMX V BAN2 510.409 1334 www.BayAreallotary,com
CAPACITY CLAIMED BY THE SIGNER
Individual
Corporate Officer
Partner
Attorney -In -Fact
Trustee
Other

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