NCC230263_FRO Submitted_20230130

NC Dept of Environmental Quality
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM OCT 3 12022
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the kr Office
and an acceptable erosion and sedimentation control plan have been completed and approve by Jahn
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 Selma South Terminal Expansion
2. Location of land -disturbing activity: County Johnston City or Township Selma
W. Oak St. 35.550441N 78308638W
Highway/Street LatltUdeineGmal degrees} LongltUdetdecimal degrees)
I Approximate date land -disturbing activity will commence: 1 1 /01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)' 7.96 (4 94 AC Prev. S.b.'ndtal)
6. Amount of fee enclosed: $ 400.00 tseoo.00 Paid in pnor trsnsmittslI 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 x❑ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Terry Murray E-mail Address [e-mail]
Phone: Office # 919-965-9442 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
TransMontaigne Operating Company L.P. 919-965-9442 919-915-1041
10
Name
2427 W. Oak Street
Current Mailing Address
Selma, NC 27576
City
Phone: Office # Mobile #
2427 W. Oak Street
Current Street Address
Selma, NC 27576
State Zip City
Deed Book No. 3505 Page No. 342
SOUTH TERMINAL- 2427 W Oak Street (Listed on deed above)
NORTH TERMINAL 2600 W Oak Street (Listed on deed above)
TransMontaigne Operating Company L.P. is the landowner of record
for both addresses listed on this common deed
State
Zip
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 mdividual(s). the names) of the owner(s) may be listed as the financially responsible party(ies)
TransMontaigne Operating Company L.P.
Company Name
200 Mansell Court East, Ste. 600
Current Mailing Address
Roswell, GA 30076
City State Zip
Phone: office # 770-518-3589
[e-mail]
E-mail Address
200 Mansell Court East, Ste. 600
Current Street Address
Roswell, GA 30076
City State Zip
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
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State 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:
Cogency Global Inc. [e-mail]
Name of Registered Agent E-mail Address
212 South Tryon Street, Suite 1000 212 South Tryon Street, Suite 1000
Current Mailing Address Current Street Address
Charlotte, NC 28281 Charlotte, NC 28281
City State Zip City State Zip
Phone: office # 866-755-0114 Mobile # Fax: [phone]
Kelly Casey
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.
Shawn L. Mongold
Typ r print naN
X
Signature
SVP, Engineering and Technical Services
Title or Authority
(J r •• Gr'.
Date
I Vicki L. Fanning , a Notary Public of the county of Cherokee
Geor la Shawn L. Mongold
State of N'.=. are ., 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 27
,day of October 2022
Notary
My commission expires June 24, 2023
" \11CK1 L FANNING
Nemtry Public. Georgia
_ = fher okeeCounIY
pay Commission Expires
June 24, 2023