NCC233427_FRO Submitted_20231116

CAPITAL GROWTH
BUCHALTER
April 11,2023
ELIZABETH PILGRIM
Direct Dial:205.263-4591
E-Mail Address:Inilerim(u�cepre.com
VIA Electronic Mail and Federal Express
DEQ
J. Randall Jones, Jr
943 Washington Square Mall
Washington,NC 27889
randall.iones a(..ncdenr.gov
Re: Goldsboro (Medical Office Place)WW,LLC
Dear Randall,
Please find enclosed the following original documents regarding the above-referenced
matter:
1. Financial Responsibility Form.
If you have any questions, please do not hesitate to contact me. Thank you for your
cooperation.
Sincerely,
fjc)i.sodkrav so/w
Elizabeth Pilgrim
Executive Paralegal for In House Counsel
Enclosures.
361 Summit Blvd.Suite 110.Birmingham AL 35243 cgbuchalter.com

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Wawa Medical Office Place
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Wayne City or Township Goldsboro
Wayne Memorial Dr 35.4010 Lon Itude decimal de reel 77.9540
Highway/Street Latltude(decimai degrees) g ( g )
3. Approximate date land-disturbing activity will commence: Fall 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.0 ac
6. Amount of fee enclosed: $$200 . The application fee 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❑ Enclosed ❑x No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chad Post E-mail Address [e-mail]
Phone: Office# 2059689217 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kenneth L Wiggins Jr 9192227468
Name Phone: Office# Mobile#
305 Breezewood Drive 305 Breezewood Drive
Current Mailing Address Current Street Address
Goldsboro, NC 27534 Goldsboro, NC 27534
City State Zip City State Zip
10. Deed Book No. Page No. 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 landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Goldsboro(Medical Office Place)WW, LLC [e-mail]
Company Name E-mail Address
361 Summit Blvd, Suite 100 361 Summit Blvd, Suite 110
Current Mailing Address Current Street Address
Birmingham, AL 35243 Birmingham, AL 35243
City State Zip City State Zip
Phone: Office# 2059689200 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 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:
National Registered Agents, Inc [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Suite 200 160 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# 9198448360 Mobile#
Karen Rozar
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.
Chad J. Post Authorized Agent
Type or print name Title or Authority
April 11, 2023
Signa ure Date
I, Elizabeth Pilgrim , a Notary Public of the County of Jefferson
State of ALABAMA, hereby certify that Chad J. Post 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 11th day of April , 20 23
I
f011inNota
Seal
My commission expires EUZABET'H PILGRIME AT LARGE
FM COMMISSION EXPIRES NOV,12,2024

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 State 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 1 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#

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