NCC233034_FRO Submitted (2)_20231030

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
R-egional Office.{Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable,place NIA in the blank.)
Part A.
1. Project Name Universal Technology Park Forza Project Mailne
2. Location of land-disturbing activity: County McDowell City or Township Marion
Highway/Street 100 Impact Drive Latitude F degreesy35•651 Longiitude(de i des1)-81.9C-6
3. Approximate date land-disturbing activity will commence:Spring 2023
4. Purpose of development(residential,commercial,industrial,institutional,etc.):industrial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 11.33
S. Amount of fee enclosed:$1200.00 . The application fee of$9 E3El_iM per acre(rounded
up to the next acre)is assessed without a ceiling amount (Example: 8.10-acre application lee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ® No ID
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity_
Name.Mike -Lovoy, P.E. E-mail Address ibo ygiaceas ]eVille. om
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
McDowell County [phone]
Name Phone: Office# Mobile#
60 E. Court Street 69 N. Main Street
Current Mailing Address Current Street Address
Marion NC 28752 Marion NC 28752
City State Zip City State Ziip
10. Deed Book No.01067 Page No.0210 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 landowners)is
an individual(s),the name(s)of the owner(s)may be listed as the financially responsible party(es).
Forza X1, Inc. [e-mail]
Company Name E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# ( Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the!and 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
Jim Leffew jim [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# Mobile# [phone]
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.
Jim Leffew Chief Executive Officer President
Type or prire_21.fla,rne Title or Authority
Th/*/& Ak/1
Signature Date
I, 1krSS(A. I— P I I Itr , a Notary Public of the County of I11 C yvki/
State of North Carolina,hereby certify that --LA LRt-roti appeared personally
before me this day and being duly sworn acknowledged tha the above form was executed� by him/her.
Witness my hand and notarial seal,this a3 day of itit Q , 20 72
4,4dfiCAA__,
,44Q
Notary
My commission expires dr—

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 Sidle 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.

Continued from item ? in Part B of the Financial Responsibility/Ownership Form for multiple parties_
Attach copies of this page as needed to list all financially responsible parties_
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#