NCC231760_FRO Submitted_20230608

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Gerber Collision - Goldsboro
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
Wayne CityTownshipGoldsboro
2. Location of land-disturbing activity: County or
McLain Street 35.3605 Lon Rude{decimal degrees)-77.927
Highway/Street L2tltude(decimal degrees) g
3. Approximate date land-disturbing activity will commence: 5/1/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):3.0
6. Amount of fee enclosed: $300.00 . 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❑ Enclosed IZI No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jeff Mosley E-mail Addressjmosley@mosleyconstruc
Phone: Office# 252-321-7744 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Harry & Mollie, LLC
Name Phone: Office# Mobile#
229 NC Hwy 111 South
Current Mailing Address Current Street Address
Goldsboro, NC 27534
City State Zip City State Zip
10. Deed Book No.281 1 Page No.413 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).
Gerber Real Estate, Inc. [e-mail]
Company Name E-mail Address
400 West Grand Avenue
Current Mailing Address Current Street Address
Elmhurst IL
City State Zip City State Zip
Phone: Office# Mobile#
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:
CT Corporation System
Name of Registered Agent E-mail Address
16 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
Raleigh NI
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.
GERBE. L COLL(sIo 1J i- C L,--s s
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.
Timothy O'Day President
Type or print name Title or Authority
Signature Date
I, f4at.rietrin.c. Ca. Bewev , a Notary Public of the County of 0-0 k I LL W O(S
State of North Carolina, hereby certify that -Trmo4-hyJ•O'ba.s/ 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 12 day of APa-IL , 20 2:6
"OFFICIAL SEAL" L1114-4AL4G1210.4k6-4.-/-
MARIANNE G.BAUER Notary
Notary Public,State of Illinois
My Commission Expires May 14,2026 My commission expires III AV I`f'• 2(4,1°