NCC231956_FRO Submitted_20230707

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT Raleigh Regional Office
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 address or phone
number is unavailable, place N/A in the blank,)
Part A.
1. Project Name NC 97 Industrial Park Shell #1
2. Location of land-disturbing activity County Nash City or Township Wilson
Highway/Street NC 97 _Latitude,a.._mal degree:;35.8361 Longitude(depmai degrees)-77.9657
3. Approximate date land-disturbing activity will commence. Summer 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 16.16
6. Amount of fee enclosed: $ 1700 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 El Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kevin Varnell E-mail Address [e-mail]
Phone: Office# 252.459.8196 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Nash County 252.462.2613
Name Phone: Office# Mobile#
120 W. Washington St. Suite 2004 120 W. Washington St. Suite 2004
Current Mailing Address Current Street Address
Nashville NC 27856 Nashville NC 27856
City State Zip City State Zip
10. Deed Book No.2545 Page No.213 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 propnetorship 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)
Nash County [e-mail]
Company Name E-mail Address
120 W. Washington St. Suite 2004 120 W. Washington St. Suite 2004
Current Mailing Address Current Street Address
Nashville NC 27856 Nashville NC 27856
City State Zip City State Zip
Phone: Office# 252.462.2613 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
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)

(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.
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.
Johnatha %oon Public Utilities and Facilities Director
Type in - Title or Authority
q 2 Z
Signature Date
I, d- �� 'r , a Notary Public of
the County of NRSk
State of North Carolina, hereby certify that 3` a 4-0.0 F>0u1`e 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 LQ day of j.k i , 20 1.)
WALE M KIN+R ryt
Notary
NAM COUNTY PLC.
My commission expires Z- 2--23

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.