NCC230990_FRO Submitted_20230414

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. (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.1. Project Name ora NCIC Phase 3 Infrastructure Temporary Access Road
2. Location of land-disturbing activity: County Alamance City or Township Mebane
Highway/Street Lake Latham Road Latitude 36 deg 05 min 38 sec Longitude-79 deg 18 min 01 sec
3. Approximate date land-disturbing activity will commence:Upon plan approval
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .68 Acres
6. Amount of fee enclosed: $$630.00 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Blake Malpass E-mail Address [e-mail]
Telephone [phone] Cell # 336-709-9955 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Clifford M. Ray, Jr. Family Limited Partnership
Name Telephone Fax Number
3402 Bentridge Drive same
Current Mailing Address Current Street Address
Mebane NC 27302 Mebane NC 27302
City State Zip City State Zip
10. Deed Book No.2799 Page No.569 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Samet Corporation bhall©sametcorp.com
Name E-mail Address
Post Office Box 8050 309 Gallimore Dairy Road
Current Mailing Address Current Street Address
Greensboro NC 27419 Greensboro NC 27409
City State Zip City State Zip
Telephone [phone] Fax Number 336-544-2594

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Arthur L. Samet [e-mail]
Name of Registered Agent E-mail Address
P. O. Box 8050 309 Gallimore Dairy Road
Current Mailing Address Current Street Address
Greensboro NC 27419 Greensboro NC 27409
City State Zip City State Zip
Telephone [phone] Fax Number 336-544-2594
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Triad Design Group, PC [e-mail]
Engineering Firm or other consultant E-mail Address
Allan Hill 336-218-8282 336-218-8010
Individual contact person (type or print) Telephone Fax Number
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 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 Person). I agree to provide corrected information should there be
any change in the information provided herein.
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Type rin am Title or Authority
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Sign u Date
I, ( VVI Qi E. rd , a Notary Public of the County of O�,(.�ICALDDO
State of North Carolina, hereby certify that 61/I Q V) A .47 L( appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal this JO day of _ k lmhey 20 'C)
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Seal A L o , P _ 1 D, 202(
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