NCC242319_FRO Submitted_20240806

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 Vanguard NE1 & NE2
2. Location of land-disturbing activity: City or Township Clayton
Highway/Street U S 4 2 E Latitude 35 . 655 Longitude —7 8 . 3 41
3. Approximate date land-disturbing activity will commence: October 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2 . 21
6. Amount of fee enclosed: $ 1, 350 . The application fee of$450.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $225 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 X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name George Venters E-mail Address gventers@vanguardpg. corn
Telephone [phone] Cell# 919-604-5480 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Flowers Holding Company, LLC
Name Telephone Fax Number
4880 NC Hwy 42 E 4880 NC Hwy 42 E
Current Mailing Address Current Street Address
Clayton, NC 28527 Clayton, NC 28527
City State Zip City State Zip
10. Deed Book No. 06125 Page No. 2-3
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):
Triple Net Ventures, LLC
Name E-mail Address
3825 Barrett Drive Suite 100 3825 Barrett Drive Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
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:
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:
George Venters gventers@vanguardpg. com
Name of Registered Agent E-mail Address
3825 Barrett Drive Suite 100 3825 Barrett Drive Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
City State Zip City State Zip
Telephone [phone] 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.
George Vent s Registered Agent
Type or print e Title or Authority
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Sig ure Date
I, i I1 I �i._ /()VV , a Notary Public of the County of YVrLI4
State of North Carolina, hereby certify that & 51ilC. VeVIk1f appeared
personally before me this day and being duly sworn/acknowledged that the above form was
executed by him. Q'
Witness my hand and irigarial seal, this 0 day of \/ , 20 olti
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