NCC231464_FRO Submitted_20230516

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. 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.
1. Project Name LNR Facility Rock Face Stabilization
2. Location of land-disturbing activity: County Caldwell City or Township Lenoir
Highway/Street Overlook Drive SW Latitude 35.8911 Longitude -81.5468
3. Approximate date land-disturbing activity will commence: November 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.82
Normal:$520 TOTAL:$2520
6. Amount of fee enclosed: $ Express:$2000 , 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 Fred Haydt E-mail Address [e-mail]
Telephone[phone] Cell# Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Tapaha Dynamics LLC C/O Corp Service CC [phone]
Name Telephone Fax Number
1600 Amphitheater Parkway 1600 Amphitheater Parkway
Current Mailing Address Current Street Address
Mountain View CA 94043 Mountain View CA 94043
City State Zip City State Zip
10. Deed Book No. 1625 Page No. 1652 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Tapaha Dynamics, LLC
Name E-mail Address
1600 Amphitheater Parkway 708 Lynhaven Dr.
Current Mailing Address Current Street Address
Mountain View CA 94043 Lenoir NC 28645
City State Zip City State Zip
Telephone [phone] Fax Number(650) 963-3309

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:
Corporation Service Company(NCSOS ID#0859528)
Name E-mail Address
2626 Glenwood Avenue, Suite 550 2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] 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:
Corporation Service Company(NCSOS ID#0859528)
Name of Registered Agent E-mail Address
2626 Glenwood Avenue, Suite 550 2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh NC 276088 Raleigh NC 276088
City State Zip City State Zip
Telephone[phone] Fax Number
(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:
S&ME, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Michael Romanello, P.E. 828-687-9080 704-525-3953
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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Ty er-ol�Drint na Title or Authority
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I �lGXRfr e/ fet ri v , a Notary Public of the County of 6aLa-1441."--
State of North Carolina, hereby certify that Cir,sevfrn GY To41) k' 1hia0,5appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
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Witness my hand and notarial seal, this ZY- day of OGta,�e,- , 20 z
ALEXANDER BARKLEY
NOTARY PUBLIC Notary
Seal CATAWBA COUNTY,NC
My commission expires 0Z-Z.'P "ZOZ�