NCC231831_FRO Submitted_20230614

Check if this project is ARPA-funded &
Attach a copy of the Letter of Intent to Fund
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 NCGO1 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: Plycem Allura Roaring River Site Improvement
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County: Wilkes City or Township: North Wilkesboro
Highway/Street: ABTCO Road Latitude(decimai degrees): 36° 11'56 N Longitude(decimai degrees): 81° 01'46 W
3. Approximate date land-disturbing activity will commence: Approximately July 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2,17 Acres
6. Amount of fee enclosed: $300. 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 & No &
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Kim Burton E-mail Address: [e-mail]
Phone: Office#: 832-706-0990 Mobile#: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Plycem USA, Inc. 832-706-0990 336-466-5309
Name Phone: Office# Mobile#
10945 State Bridge Rd Suite 401-304 1149 ABTCO Rd
Current Mailing Address Current Street Address
Alpharetta GA 30022 North Wilkesboro NC 28659
City State Zip City State Zip
10. Deed Book No.: 01184 Page No.: 0409 Provide a copy of the most current deed.

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The above information is true and correct to the best of my knowledge and belief and was provided
NM 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.
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State of North Carolina, hereby certify that_Wt-, lam of 6 /419`l appeared personally 7
before me this day and being duly sworn acknowtdged that the above form was executed by him/her. N
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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).
Plycem USA, Inc. [e-mail]
Company Name E-mail Address
1149 ABTCO Rd. 1149 ABTCO Rd.
Current Mailing Address Current Street Address
North Wilkesboro NC 28659 North Wilkesboro NC 28659
City State Zip City State Zip
Phone: Office#: 832-706-0990 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 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)
(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)