NCC242328_FRO Submitted_20240813

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 Nutrien Ag Solutions - Terra Ceia
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
NA
2. Location of land-disturbing activity: County Beaufort City or Township Pantego
Swindell Road 35.604159 -76.678031
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 3/1/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 23.7
6. Amount of fee enclosed: $2,400.00 . 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 0 Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Paul Johnson E-mail Address [e-mail]
Phone: Office# 970-685-3747 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Meadowoods LLC 252-235-3299 NA
Name Phone: Office# Mobile#
9295 Old Lewis School Road 9295 Old Lewis School Road
Current Mailing Address Current Street Address
Middlesex, NC 27357 Middlesex, NC 27357
City State Zip City State Zip
10. Deed Book No.1 826 Page No. 536-536 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).
Nutrien Ag Solutions - Paul Johnson [e-mail]
Company Name E-mail Address
3005 Rocky Mountain Ave 3005 Rocky Mountain Ave
Current Mailing Address Current Street Address
Loveland CO 80538 Loveland CO 80538
City State Zip City State Zip
Phone: Office#
970-685-3747 Mobile#[phone]
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:
NA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
NA
Name of Individual to Contact(if Registered Agent is a company)
(b) If the FinanciallyResponsible Party not a resident of North Carolina p is , give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake CT Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office# 866-665-5799 Mobile# NA
NA
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 of Assumed Name.
NA
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
correc d information should there be any change in the information provided herein.
‘vC
Type or flit-
yp m Title or Authority
10.-/ - a
Signature Date
I, tli\dw Vl(/VA. , a Notary Public of the County of k_A.li'L i'Yl- '
Calorado
State of Nodh_ a.ro.ti.raa, hereby certify that fi u.i F. J b kIn-66 VI 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 le8 day of OCA-Ob- Y , 20 Z3
dt&44,� Jj/
4 / L
ry
My commission expires J CAVIL g,
LINDA N.O'CONNELL
NOTARY PUBLIC
STATE OF COLORADO
NOTARY ID 20114034496
MY COMMISSION EXPIRES JUNE 08,2027

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:
Vernon Van Daw, Jr. NA
Name Phone: Office# Mobile#
362 Neck B Road 362 Neck B Road
Current Mailing Address Current Street Address
Pantego NC 27860 Pantego NC 27860
City State Zip City State Zip
Deed Book No.893 Page No.447 Provide a copy of the most current deed.
Landowner 3 of Record:
Vernon Van Daw, Jr. NA
Name Phone: Office# Mobile#
362 Neck B Road 362 Neck B Road
Current Mailing Address Current Street Address
Pantego NC 27860 Pantego NC 27860
City State Zip City State Zip
1204 312-315
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 I 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#
1

Meadowoods LLC
9295 Old Lewis School Road
Middlesex, NC 27357
Vernon Van Daw,Jr.
362 Neck B Road
Pantego, NC 27860
October 13, 2023
1
Nutrien Ag Solutions, Inc.
3005 Rocky Mountain Ave
Loveland,CO 80538
RE: New Retail Fertilizer&Ag Chemical Facility, Beaufort County
To Whom it May Concern:
This letter gives Nutrien Ag Solutions), Inc. (Financially Responsible Party) authority to pursue plan
approvals for erosion and sediment control plans for the New Retail Fertilizer&Ag Chemical Facility,
located at 1054 Swindell Road, Pantego. We also give permission for Nutrien Ag Solutions, Inc. to
preform construction on this property.
Respectfully,
'D IA) ---1
Vernon Van Daw,Jr.