NCC224059_FRO Submitted_20221213

FINANCIAL RESPONSIBILITYIOWNERSHIP 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
1. Project Name+/-20,000-SF Distribution Facility Expansion for CCBCC-Fayetteville
2. Location of land=disturbing activity: CountyCumberland City or Township. N/A
Highway/StreetTOm Starling Rd Latitudes „ is ees)34'952 Longitude(dedmalcwfts)78.893
3. Approximate date land -disturbing activity will commence: November 1, 2022
4. Purpose of development (residential, commercial, industrial, Institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3, 0
6. Amount of fee enclosed: $300 . 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 art erosion and sediment control plan been filed? Yes ® Encbsed ® No Q
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ethan Hart E-mail [e-mail]
Phone: Office # 803-331-2991 Mobile #i; 803-331-2991
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CCBCC Operations, LLC
Name
5001 Chesapeake Dr.
Current Mailing Address
Charlotte, NC 28216
City
State Zip
704-488-0429 704-488-0429
Phone: Office # Mobile #
5001 Chesapeake Dr.
Current Street Address
Charlotte, NC 28216
City
State
Zip
10. Deed. Book No.6757 Page No 456 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 landowners) is
an indi%ddual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
GGBGG Operations, LLG
Company Name
5001 Chesapeake Dr.
Current Mailing Address
Charlotte, NC 28216
City
Melanie.Sabetla@Coke,Corvsolidated.com
E-mail Address
5001 Chesapeake Dr.
Current Street Address
Charlotte, NC 28216
State Zip City
State
Phone: Office # 704-488-0429 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:
N/A
Name of Registered Agent
Current Mailing Address
NY 9tafe Zip
Phone: Office #
E-mail Address
Current Street Address
city .9fafe Zip
Mobile #
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:
CT Corporation System
Name of Registered Agent
28 Liberty St.
Current Mailing Address
New York, NY 10005
City State Zip
[e-mail]
ctcorporation.com
E-mail Address
160 Mine Lake Ct. Ste. 200
urrent Street Address
Raleigh, NC 27615
City State Zip
Phone: Office # 212-894-8940 Mobile # [phone]
Robert Ingato
Name of Individual to Contact (if Registered Agent Is a company)

(c) If then 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.
N/A
Company MA 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 attomey-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), t agree to provide
corrected information should there be any change in the information provided herein.
Melanie Sabella
Ty rin n me
Signature
VP, Technical Services
Title or Authority
Oaf— a
I, _f4\0. Ge (��©c'/� , a Notary Public of the C/oun of 1�(.EC'�i'Jlui(gc�,z
State of North Carolina, hereby certify that �' 1�� .:� 14e 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 o - 2� , 20
Race ,00drich
Notary Public
Iredelf County ofary
M mission Ex res 6 8 2026
My commission expires_