NCC232328_FRO Submitted_20230803

Check if this project isARPA-fumdmd O
Attach a copy of the Letter of Intent b»Fund
FINANCIAL RESPONSI-1; ITYJOWNERSHMFORM
SEDIMENTATION POLLLMON CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
sctk/ih/ under a common plan of development of this size as covered by the NCG01 permit, before this form
aruxmn acceptabiemros=.and sedwrtentaWn mortrc_4 plan. have been c��etted and approved by the Land
Ouo{ky Geodnn' 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.
Penske Concord
1. Project Name
*If this project involves American Rescue Plan Act(ARPA) funcs, 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 uf land-disturbing activity: County Cobonua City orTownship Concord
Highway/Stnaat4G5O Global Avenue NyyLeUtude(ded,=/'mom,*35.43128OLongitudew°*""/vegre,s>-8D.GS53OU
����
I Appn��m�daba�n�d�b:���acb�ym�!�m:�:��
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
�� To�da�nm�gm�i��u�bmdor uncovered (�duding�f�w�e bmnowand waste ereao): 16.00ocreo
G. Amount of fee enclosed: $ -O-(Paid previously) The application fee of*1OU.00 per acre (rounded
uptu the next acre) is assessed without o ceiling amount (Exmmp|e: 8.1O-acna application fee is$GOO).
Checks should be addressed hzNCDEC>.
7. Has mn erosion and sediment control plan been filed? YanCZ Enclosed [] No []
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Robert GaAbuo. Regional Facilities yNanaQer-_nnai|Address ro
[e-mail]
Phone: OMioe# Mobile# [phone]
&. Lawd��n����of��cun1(�Uauhaooump�n�dpaQwi��ks1od6Nune!ownam).
Penske Truck Leasing Co. LP 678'502-8844
Nome Phone: Offine# yNobi|e#
2G75 Morgantown Road same
Current Mailing Address ' Current Street Address
Reading, PA 19607
same
City 8haba Zip city 8teba Zip
10. Deed Book No. 15513 Page No. 0172 Provide e 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).
Penske Truck Leasing Co. LP [e-mail]
Company Name E-mail Address
2675 Morgantown Road same
Current Mailing Address Current Street Address
Reading, PA 19607 same
City State Zip City State Zip
Phone: Office# 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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue Ste 550 same
Current Mailing Address Current Street Address
Raleigh, NC 27608 same
City State Zip City State Zip
Phone: Office# 800-927-9800 Mobile# n/a
Sonya Cordell- Litigation Management Service
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.
n/a
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.
Robert Gerbus Regional Facilities Manager
Type or print name Title or Authority
x JiLLAL 7/1-1ra3
Signature Date •
I, Mok n A • ,S QQ..li , a Notary Public of the County of C :E'Wru .:k----
State of C{hereby certify that Ku v.".1 a 65�.r41 4. ppeared 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 ( 'i 'day of ;y , 20 9-3
�6`cAR - Notary
naGIA - My commission expires 6 :s""` o 't a
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