NCC224030_FRO Submitted_20221213

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 NIA in the blank,)
Part A.
1. Project Name Blldan, LLC
2. Location of land -disturbing activity: County Wayne City or Township Fork Township
Highway/Street Leslie Rd. (SR 1327) Latitude(decimal degrees) 35.4259 Longltude(decimal degrees)-78.0467
3. Approximate date land -disturbing activity will commence: October, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.5
6. Amount of fee enclosed: $ 900 . 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 ❑ Enclosed ED No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Danny Sasser E-mail Address [e-mail]
Phone: Office # 919-734-1045 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bildan, LLC 919-734-1045 919-922-4203
Name
2530 US Hwy. 70 West
Current Mailing Address
Goldsboro, NC 27530
Phone: Office # Mobile #
2530 US Hwy. 70 West
Current Street Address
Goldsboro, NC 27530
City State Zip City State Zip
10. Deed Book No. 2367 Page No. 640 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).
Bildan, LLC
Company Name
2530 US Hwy. 70 West
Current Mailing Address
Goldsboro, NC 27530
[e-mail]
E-mail Address
2530 US Hwy. 70 West
Current Street Address
Goldsboro, NC 27530
City State Zip City State Zip
Phone: Office # 919-734-1045 Mobile # [phone]
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:
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)
(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.
Danny Sasser
or print na
Signature
Member/Manager
Title or Authority
Date
Doris S. McFatter , a Notary Public of the County of Wayne
State of North Carolina, hereby certify that Danny Sasser 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 27 day of October 2022
go S. McF,�rl�9�i ;.
NOTARY Notary
PUBLIC My commission expires January 3, 2026
COUwN�.�`�•