NCC230153_FRO Submitted_20230127

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. Eastfield CrossingEastfield Business Pk S Building #1
1. Project Name - ness Park 9
2. Location of land -disturbing activity: CountyJohnston City or Township Selma
Highway/Street W Blanche St Latitude 35.5184 Longitude -78.2843
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.62AC (10.59aoapproved uderJOHNS-2021-0„)
0.3 AC (Add'I AC proposed with this submittal)
See attached Permit Fee
6. Amount of fee enclosed: $ summary . 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Dougherty E-mail Address [e-mail]
Phone: Office # 919-965-5661 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Eastfield Associates, LLC 919-965-5661 919-965-8568
Name Phone: Office # Mobile #
101 S Raiford St. Suite 200 101 S. Raiford St. Suite 200
Current Mailing Address Current Street Address
Selma, NC 27576 Selma, NC 27576
City State Zip City State Zip
10. Deed Book No. 5174 Page No 921 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).
Eastfield Associates, LLC
Company Name
101 S. Raiford St Suite 200
Current Mailing Address
Selma, NC 27576
[e-mail]
E-mail Address
101 S Raiford Suite 200
Current Street Address
Selma, NC 27576
City State Zip City State Zip
Phone: Office # 919-965-5661 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.
Typ . ❑ print name Title or Authority
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S�nature Date
Ing I, peaam a Notary Public of the County of �R,n
State of North Carolina, hereby certify that KVNI IV l i IIC. '1 appeared personally
before me this day and being duly sworn acknowledged that the abo a form VVjs executed by him/her.
Witness my hand and notarial seal, this day of M 24 VO j
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