NCC240005_FRO Submitted_20240103

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 Actbefore 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 typo or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the b|anh.)
Part A.
Mt. ��|'\/(� ��'C�|�9 - Site |Ol[>F[]\/��O0���t��
1� Project Name '"'^' ~~'' Pickle'~' ~�'^ Improvements
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2. Location of|and'dioturbing ard�ih/� County � C(tyorTuwnship —
VV /�gh ��f 35.3e1461 �o.o1sao1
Highway/Street ` ` Ash'' ~^ L*�itudaw"m�°/*m��w Long�udo/u"u=°/v"w~°"/
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3. Approximate dob* land-disturbing activity will commence: January '-°^-`
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4. Purpose of development(�mkienUa|. commeru�|. indus��|. inmd�d�na|. o�j: 'Industrial
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5. Total acreage disturbed or uncovered (including off-site bornowandwest 1 waste ' '^-
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8. An�ountof fee enclosed: $ RO
°-^'" The application fee of$1OO.00 per acre(rounded
upto the next acre) io assessed without a ceiling amount (Example: 8.1O-acna application fee ia$90D).
Checks should be addressed toNCDEO.
7. Has on erosion and sediment control plan been filed? Yeo[] Enclosed 5XI No []
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Lucas \8/��U��[ [e-mail]
Name ^- Waller E'moi|Addreso' ^ �� ^ ' ' '~ '
919-658-2535 EXt3202
Phone: Office Mobile#
B. Landowner(s) of Record (attach accompanied page to list additional owners):
Mount ��|' Pickle ��
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Name Phone: Office# Mobile#
1 Cucumber �|n�
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Current Mailing Address Current Street Address
Mount O|'Ve. NC 28365
City State Zip City State Zip
10, Deed Book No.3650 883 Provide a copy of the most current deed.

PartB'
1. Company(kas)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
oni,dividuo/(s). the namek$of the omner(s)may bn listed as the fivanoia»yresponsible perty(iea),
Mount Olive Pickle Company '1bC]VV63n@mf[)|'v8p'ck|es.c{Jm
Company Name E-mail Address
1 Cucumber Boulevard rH 1 Cucumber Blvd
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Current Mailing Address Current Street Address
Mount Olive, W/~ 28365 Mount Olive, 0C 28365
City State Zip City State Zip
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Phone: Df5co# ° '° "" ' -`' "" Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the |andmwna/soignedanddatedwrittenoonoantforthoapp|icanttooubmitadrafterosionandsedimenbaUon
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:
William H' Bryan bb7VaO(d)mtn|'\/ep'cWes.cC]m
Name of Registered Agent E-mail Address
PO Box 609 1 Cucumber Blvd
Current Mailing Address Current Street Address
Mt. O|'V8, YyF^ 28365
City Gbde Zip City State Zip
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Phone: Of�m»# " '= "� ' "" '" Mobile#
Name of Individual hu Contact(if Registered Agent isacompany)
(b) If the Financially Responsible Party is not o resident of North Cano|ina, 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 iaocompany)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company in 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 mf 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-|n-faot, orif not an individua|, by an officar, d|rector, portner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected information should there be any change in the information provided herein.
Richard D. Bowen Executive VP/CFO
Type or print name Title orAuthority
^/ /1 11/29/23
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Signature Date
|. / L4 vin k\ / ' i \ 'ayv--,s . a Notary Public of the County of k\/CkW /q---'
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State ofNo�h(�arolina. hereby oo�ifvthat p~�"'*'u^kt� ^�' 'a�wf*) appeared personally
before nne this day and being duly sworn acknowledged that the above form was executed byhinl/har.
Witness ha d and notarial oeo|` thia~�}2�-'day of QW r- . 20Q2
1pR Y Notary
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