NCC231329_FRO Submitted_20230523

JOHNSTON COUNTY FINANCIAL,RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION PQLLUTION 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
Johnston County Department of Public Utilities. (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 Browning Mill - Stage 2
2. Location of land-disturbing activity: City or Township Johnston County
Highway/street Stotts Mill Road Latitude 35.75279 Longitude-78.35368
3. Approximate date land-disturbing activity will commence:April 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8 ac
6. Amount of fee enclosed: $5175 (previously paid) The application fee of$380.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $125 per acre for each
additional acre (rounded up to the next acre). Individual residential lots plans are$100 per lot.
7. Has an erosion and sediment control plan been filed? Yes No ✓ Enclosed ri
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kim Dover E-mail Address [e-mail]
Telephone [phone] cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
RBV Mill, LLC
Name Telephone Fax Number
3434 Kildaire Farm Road, Suite 135 2046 Energy Drive
Current Mailing Address Current Street Address
Cary NC 27518 Apex NC 27502
City State Zip City State Zip
10. Deed Book No. 06420 Page No. 0008
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):
Rex Vick, RBV Mill LLC [e-mail]
Name E-mail Address
3434 Kildaire Farm Road, Suite 135 2046 Energy Drive
Current Mailing Address Current Street Address
Cary NC 27518 Apex NC 27502
City State Zip City State Zip
Telephone [phone] Fax Number

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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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 inform tion should there be any change in the information provided herein.
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, r , a Notary Public of the County of 6�� �,
State of North Carolina, hereby certify that ,�' G �� �- appeared
personally before me this day and being duly sworn acknowledged thf the above form was
executed by him4 6.747 i'f,/ , N/ 4-4 e-
itness m hand and notarial seal, this I day of ,P'? / , 20 2-3
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