NCC233164_FRO Submitted_20231023

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 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 Rose Hill Pump Station and Force Main
2. Location of land-disturbing activity: County Duplin City or Township Rose Hill
Hwy 117 34.858786 -78.030680
Highway/Street Latitude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence:
June 1, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):5.4
6. Amount of fee enclosed: $Cnn_` �'00 The application tee 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 Chris ivlurray E-mail Address [e-mail]
910-990-7921
Phone: Office# Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
See Attached
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State lip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

(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 In is true and correct to the best of m i 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.
Chris Murray Corporate Environmental Manager
Type print name Title or Authority
/112,41.023
ignature Date
i, Qe y r i C , a Notary Public of the County of 1IL N-I Al
State of North Carolina, hereby certify that C_kr \RY r appeared personally
before me this day and being duly sworn acknowledged that the abofie form was executed by him/her.
Witness my hand and notarial seal, this a 7 day of a , 2g�3
•
Notary
My commission expires /--20-ao,Z5
PublIC
DupNotaryiin County
i����;,'H C p R0‘\���

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).
House of Raeford [e-mail]
Company Name E-mail Address
3333 US Hwy 117 South 3333 US Hwy 117 South
Current Mailing Address Current Street Address
Rose Hill NC 28458 Rose Hill NC 28458
City State Zip City State Zip
Phone: Office# 910-990-7921 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 AddYess 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)

ATTACHMENT
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
PROJECT NAME: ROSE HILL PUMP STATION & FORCE MAIN
Landowners of Record:
NC DOT
Moule, Mary E Merritt & Hus Moule, Walter
PARCEL ID: 11-1290
PIN: 249000007210
DB: 1417, PG: 613
NASH JOHNSON & SONS FARMS, INC.
PARCEL ID: 12-1931
PIN: 249000047224
DB: 561, PG: 57
ROSE HILL POULTRY CORP.
PARCEL ID: 12-1942
PIN: 249000151199