NCC242118_FRO Submitted_20240716

Check if this project is ARPA-funded E
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 NCGO1 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 Cambro Building 2
*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 Alamance City or Township Mebane
Highway/Street NC HWY 119 Latitude(decimal degrees)36.0970 Longitude(decimai degrees) 79.2935
3. Approximate date land-disturbing activity will commence: January 31,2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial Warehouse
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 21.45 ac
6. Amount of fee enclosed: $ 2,200.00 . 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 ge No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jeff Molitor E-mail Address ieff.molitornmrk.com
Phone: Office# 949-608-2025 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
A Campbell Holdings LLC
Name Phone: Office# Mobile#
5801 Skylab Road
Current Mailing Address Current Street Address
Huntington Beach CA 92647
City State Zip City State Zip
10. Deed Book No. 3957 Page No. 0701 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).
A. Campbell Holding LLC.
Company Name E-mail Address
_P.O Box 2000
Current Mailing Address Current Street Address
Huntington Beach CA. 92647
City State Zip City State Zip
Phone: Office# 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:
Argyle Campbell [e-mail]
Name of Registered Agent E-mail Address
_P.O Box 2000
Current Mailing Address Current Street Address
Huntington Beach, CA. 92647
City State Zip City State Zip
Phone: Office# 714-848-1555 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:
Steel, C Thomas, Jr [e-mail]
Name of Registered Agent E-mail Address
P.O. Box 2290 1694 Westbrook Avenue
Current Mailing Address Current Street Address
_Burlington, NC. 27216 Burlington, NC 27215-9700
City State Zip City State Zip
Phone: Office#_336.270.4440 Mobile#
C. Thomas Steele, Jr
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

(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.
t t)RE6-1Type or print nzotit)03
Title or Authority
Sig e Date
I, , a Notary Public of the County of -R`rt,
State of North Carolina, hereby certify that 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 day of , 20 I
Notary
My commission expires
n Co—) .
•

CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189
Y,0c,0rerc:C.. :0cs*,ccs cr0c. c ,cLt .
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document.
State of California
County of Olia,VIC!
On pm[Lity-1,1 before me, t17((IY'I )y) 11
1I ,
Dag O2 v/Here Insert Name and Title of the Officer
personally appeared k'9,9 , C/V) f I
I Name(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s)on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is true and correct.
�ti�•�`.> + SANDRA M.SMITH
Notary Public-California WITNESS my hand and official seal.
E Orange County
V,ArAvil
�� Commission z 2375054
` My Comm.Expires Sep 13.2025 },,,�
Signature 1.yt ti
Signature of Notary Public
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: Document Date:
Number of Pages: Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:
__I Corporate Officer — Title(s): ❑ Corporate Officer — Title(s):
Partner — Limited General ❑ Partner — ❑ Limited Ii General
J Individual 1 Attorney in Fact ❑ Individual ❑Attorney in Fact
Trustee L I Guardian or Conservator El Trustee ❑ Guardian or Conservator
Other: ❑ Other:
Signer Is Representing: Signer Is Representing:
A.x—e :ce x^rz;�c==xxuv ecc_.-mac..v,w--
©2014 National Notary Association •www.NationalNotary.org • 1-800-US NOTARY(1-800-876-6827) Item #5907

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#
kf
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#
si

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.