NCC241335_FRO Submitted_20240612

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 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 Chemours Sediment Trap Installation
2. Location of land-disturbing activity: County Cumberland and Bladen City or Township Hollow
Highway/Street 22828 NC-87 Latitude(decimai degrees) 34.8488 Longitude(decimai degrees) -74.8289
3. Approximate date land-disturbing activity will commence: January 1, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): _ Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.49
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 12 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Sebastian Bahr E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
The Chemours Company [phone]
Name Phone: Office# Mobile#
22828 NC Highway 87 W 22828 NC Highway 87 W
Current Mailing Address Current Street Address
Fayetteville NC 28306 Fayetteville NC 28306
City State Zip City State Zip
10. Deed Book No. 00729 Page No. 461-468 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).
The Chemours Company [e-mail]
Company Name E-mail Address
22828 NC Highway 87 W 22828 NC Highway 87 W
Current Mailing Address Current Street Address
Fayetteville NC 28306 Fayetteville NC 28306
City State Zip City State Zip
Phone: Office# [phone] 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:
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 ofAssumed Name.
Company D8AName
(d) |f order 0ofacilitate Express ParmittinQ, it is necessary to be able to contact the engineer orother
consultant who can assist in providing any necessary information regarding the plan and its preparation:
GE(]SerViQes. LLC CbUtier@teamU9S.000O
Engineering firm nr other consultant E-mail Address
Chris Butler [phone]
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 attornay-in-foct, or if not an individua{, by an officer, d{nsctor, partner, 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.
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Sgnaturm Date
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|. �00J ,� . a Notary Public nf the County of ke'] cas;ll C.
State of North Cmro|ina, hereby certify that —�~ �� E appeared personally
before rne this day and being duly sworn acknowledged that the above form was executed byhinn/hmr.
Witness my hand and notarial aeo|. this ^l day of bcc"6 e-(— . 20
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Notary /
Myoommio�on �pim� �� V �7l����'
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STATE vrucL~vvAnE

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#