NCC232142_FRO Submitted_20230718

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 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 Telephonics Corporation/TTM Technologies, Inc. - Building Expansion
*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).
2. Location of land-disturbing activity: County Pasquotank City or Township Providence Tnsp
Highway/Street Corporate Drive Latitude(decimai degrees)36.3610 -76.2958
Longitude(decimal degrees
3. Approximate date land-disturbing activity will commence:June 26, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.95
6. Amount of fee enclosed: $500.00 . 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 ❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rolley Davis E-mail Address [e-mail]
Phone: Office# 757-422-2400 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Telephonics Corporation 631 .549.6575
Name Phone: Office# Mobile#
112 Corporate Drive 112 Corporate Drive
Current Mailing Address Current Street Address
Elizabeth City, NC 27909 Elizabeth City, NC 27909
City State Zip City State Zip
10. Deed Book No. 1341 Page No.489 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).
Telephonics Corporation/TTM Technologies, Inc [e-mail]
Company Name E-mail Address
112 Corporate Drive 112 Corporate Drive
Current Mailing Address Current Street Address
Elizabeth City, NC 27909 Elizabeth City, NC 27909
City State Zip City State Zip
Phone: Office# 631 .549.6575 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:
Corporation Service Company
Name of Registered Agent E-mail Address
2626 Glenwood Ave., Suite 550 2626 Glenwood Ave., Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
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.
Jack Enright VP/GM (Owner's Representative)
Type or print name Title or Authority
S7z2-/z3
Sign t Date
I, Siai'iLe1Ziy , , a Notary Public of the County of /&LS �L-1
State of Nerrti aro �a,` 1i ereby certify that J(t En,1 appeared personally
before me this day and being duly sworn acknowledged that the dove form was executed by him/her.
Witness my hand and notarial seal, this g L day of Plat , 20 0�
i2t..2,ari Zitily/4' i
N ary
Seal -7
My commission expires June r 0"� I
SUSAN LENZINI
!NOTARY PUBLIC,STATE OF NEW YOU
Registration Na 01LE6094933
Qualified in y County
My Commission Expires N'Iu11t 36,s zi Q i