NCC232765_FRO Submitted_20230914

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°qR FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity that disturbs one or more acres as covered by the Town of
Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Clayton. Lots smaller than one
acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and
Sedimentation Control Ordinance and are required to complete this form. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Wash Factory I I I
2. Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/street Briarcliff Drive Latitude 35.645168 Longitude-78.418990
3. Approximate date land -disturbing activity will commence. 6-1-2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.93
6. Has an erosion and sediment control plan been filed? Yes No Enclosed
7. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Rod Holloman E-mail Address [e-mail]
Telephone cell # 252-908-4477 Fax #
8. Landowner(s) of Record (attach accompanied page to list additional owners)
A & H 2, LLC _
Name Telephone Fax Number
179NC97E 179NC97E
Current Mailing Address Current Street Address
Tarboro NC 27886 Tarboro NC 27886
City State Zip City State Zip
9. Deed Book No. 6204 Page No. 885 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
A & H 2, LLC
Name
179 NC 97 E
Current Mailing Address
Tarobor NC
City State
Telephone [phone]
[e-mail]
E-mail Address
179NC97E
Current Street Address
27886 Tarboro NC 27886
Zip
City
Fax Number
State
Zip

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Rod Holloman
Type or print name
Sign ture
Member
Title or Authority
Date
Qa a Notary Public of the County of l 's
State of North Carolina, hereby certify that 1`odrer 7. 4Q����a-� appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this
ANGELA M CLARK
NOTARY PUBLIC
NASH COUNTY, NORTH C�OLINA
MY COMMt EXPIRES "° ' Zq
30 day of Mev cJ 20 Z
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