NCC240184_FRO Submitted_20240125

JOHNSTON COUNTY 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
Johnston County Department of Public Utilities. (Please type or print and, if the question is not applicable or
the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name NN IFP Expansion Trailer Complex - Phase 1
2. Location of land-disturbing activity: City or Township Clayton
Highway/Street Powhatan Latitude 35.61651 Longitude-78.39585
3. Approximate date land-disturbing activity will commence:On-going
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):9.62
6. Amount of fee enclosed: $3,800.00 . The application fee of$380.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $125 per acre for each
additional acre(rounded up to the next acre). Individual residential lots plans are$100 per lot.
7. Has an erosion and sediment control plan been filed? Yes ❑ No ❑ Enclosed I I
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lisa Florack E-mail Address [e-mail]
Telephone [phone] Cell# same Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
NOVO NORDISK 919.550.2200
Name Telephone Fax Number
3612 POWHATAN RD.
Current Mailing Address Current Street Address
CLAYTON NC 27527
City State Zip City State Zip
10. Deed Book No. Page No.
Part B. .
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
BE&K Building Group [e-mail]
Name E-mail Address
710 Slater Rd., Suite 400
Current Mailing Address Current Street Address
Morrisville NC 27560
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Patrick Chisholm Ai President
Type" �v* , J Title or Authority
mow. .%/ /e�/a.‘.1
S tur Dat
I, IJoiv t • 60fd • , a Notary Public of the County of w '
•
State of NorNo4 Carolina, hereby certify that "Po.k'rl(/`L 0)/1.ASefnOUM, appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and § this 4 day of OM-CAW( , 20 2 3
O
Notary
Se P U B L e c‘�, 10. 2613
q My commission expires

Certificate of Coverage
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL,AND LAND RESOURCES
GENERAL PERMIT NO.NCG010000
NC Reference No.NCG01-2023-2591
Certificate of Coverage No.NCC232591
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1,other lawful standards and regulations
promulgated and adopted by the North Carolina Environmental Management Commission,and the Federal Water
Pollution Control Act,as amended,
BE&K Building Group
is hereby authorized to discharge stormwater associated with CONSTRUCTION ACTIVITIES to surface waters of North
Carolina from a site located at:
Novo Nordisk Early Grading Package
Powhatan Rd
Clayton
Johnston County
in accordance with the effluent limitations,monitoring requirements,and other conditions set forth in N.C.General Permit
No. NCG010000.
This Certificate of Coverage is affiliated with E&SC Plan Project No.JC#23-051-P
This Certificate of Coverage shall become effective 9/27/2023.
This Certificate of Coverage shall remain in effect until rescinded or expired.
This Certificate of Coverage will expire on the anniversary of its effective date unless it is renewed by payment of the
annual administration and compliance fee.
C f d
William E.Vinson,Jr., PE,CPESC,CPM, Interim Director
Division of Energy,Mineral,and Land Resources
By the Authority of the Environmental Management Commission