NCC223166_MODIFICATION Supporting Doc (Revised FRO)_20220919

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
2
3.
4.
5.
6.
7
E.
a
Project Name Cardinal Stream Mitigation Project
Location of land -disturbing activity: County Union
City or Township Monroe
Magnum Dairy Rd. 34.914686-80.486973
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
Approximate date land -disturbing activity will commence: August 1 st, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Stream Mitigation
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 48
Amount of fee enclosed: $4,800 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed x❑ No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kirkpatrick E-mail Address [e-mail]
Phone: Office #
Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Buford Township Farms, LLC
Name
P.O. Box 429
Current Mailing Address
Monroe, NC 28111
City State
10. Deed Book No. 07279
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. 0643 Provide a copy of the most current deed.

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 proprietorship 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).
Resource Environmental Solutions, LLC [e-mail]
Company Name E-mail Address
3600 Glenwood Ave. Suite 100 3600 Glenwood Ave. Suite 100
Current Mailing Address
Raleigh NC, 27612
City State Zip
Phone: Office #
Current Street Address
Raleigh NC, 27612
City State
Mobile # [phone]
Zip
Note: If the Financially Responsible Party 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 Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Corporation Service Company
Name of Registered Agent
2626 Glenwood Ave. Suite 550
Current Mailing Address
Raleigh NC, 27608
[e-mail]
E-mail Address
2626 Glenwood Ave. Suite 550
Current Street Address
Raleigh NC, 27608
City State Zip City State Zip
Phone: Office # 1-800-927-9801 x62323 Mobile #
Laura Weigle
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible 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 State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(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.
Ben Eubanks
VP & Regional General Manager
Typ�n rint name Title or Authority
a �- I Zv
Sig ata a Date
I, TJ�1i\cJ1v�t„ i�i�tl�r✓�A' a Notary Public of the County of City Of Richmond
State of Virginia, hereby certify that xy) k�� 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 114 day of r 20,E
Bethany Suzanne Whitfield
NOTARY PUBLIC N tart'
_m Commonwealth of Virginia
o °F Reg.* 7938501
y�rgRY a�6 o My Commission Expires My commission expires , (
December 31, 2025

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 list all landowners.
Landowner 2 of Record:
David D. and Deborah A. Whitley
Name
P.O. Box 1045
Current Mailing Address
Monroe, NC 28111
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
Deed Book No. 809 Page No. 131 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
Deed Book No. Page No.
Landowner 4 of Record:
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book No._
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No
Current Street Address
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.

Continued from Item 1 in Part 8 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #