NCC233300_FRO Submitted_20231107

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 controlplan have been completed and approved
p p pp 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 West Pharmaceutical Kinston Parking Upgrades
2. Location of land-disturbing activity: County Lenoir City or Township Falling Creek
Highway/Street 1028 Innovation Way Latitude(decimal degrees) N35.2625° Longitude(decimai degrees)W77.6722°
3. Approximate date land-disturbing activity will commence: Upon Plan Approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (includingoff-site borrow and waste areas): 1.17 Acres
9 )
6. Amount of fee enclosed $200 + $500= $700. The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name_ Charles Witherspoon E-mail Address Charles.Witherspoonnwestpharma.com
Phone: Office# 252-522-8968 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
West Pharmaceutical Services, Inc. 252-522-8968
Name Phone: Office# Mobile#
1028 Innovation Way 1028 Innovation Way
Current Mailing Address Current Street Address
Kinston NC 28504 Kinston NC 28504
City State Zip City State Zip
10. Deed Book No. 1330 Page No. 165 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.) lf 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).
West Pharmaceutical Services, Inc.
Company Name E-mail Address
1028 Innovation Way 1028 Innovation Way
Current Mailing Address Current Street Address
Kinston NC 28504 Kinston NC 28504
City State Zip City State Zip
Phone: Office# 252-522-8968 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 Services Company SOPOcsglobal.com
Name of Registered Agent E-mail Address
2626 Glenwood Avenue, Suite 550 2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Phone: Office# 800-927-9800 Mobile#
Litigation Management Services
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Triad Design Group, PC ahillktriad-designgroup.com
Engineering firm or other consultant E-mail Address
L. Allan Hill, PE 336-218-8282 336-706-0289
Individual contact person (type or print) Phone: Office# Mobile#
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.
Charles Witherspoon VP &Treasurer
Type or print name Title or Authority
4414/ - 5/31z3
Signature Date
n I
I, ,Aarrej"t -Par Ler , a Notary Public of the County of -UrVr�°� Yl
Nev-t ScrSck v
State of , hereby certify that C,\f14fk-S VJ ti-her S pcon appeared 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 3 day of a�
Notary
Seal My commission expires GARRETT N. PARKER
Corrinllaakxr M 30203373
Notary Public.State of New JerseY
My Commission Expires
October 7,2027