NCC242712_FRO Submitted_20240909

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 IAA Expansion
2. Location of land-disturbing activity: City or Township Clayton NC
Highway/Street Sadisco Road Latitude 35d35'19.58" Longitude 78d24'08.23"
3. Approximate date land-disturbing activity will commence: July 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 34.00 AC (prey.)
+ 5.00 AC (new)
6. Amount of fee enclosed: $2,000 . The application fee of$400.00 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 ✓
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kyle Paramski E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
George A McFayden III 919-561-4099 N/A
Name Telephone Fax Number
1453 Page Circle 1453 Page Circle
Current Mailing Address Current Street Address
Fairmont NC 28340 Fairmont NC 28340
City State Zip City State Zip
10. Deed Book No. 4521 Page No. 360
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):
Insurance Auto Auctions Corp. [e-mail]
Name E-mail Address
Two Westbrook Corporate Ctr, Ste 1000 Two Westbrook Corporate Ctr, Ste 1000
Current Mailing Address Current Street Address
Westchester IL 60154 Westchester IL 60154
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
Corporation Service Company [e-mail]
Name E-mail Address
2626 Glenwood Ave Ste 550 2626 Glenwood Ave Ste 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number N/A
(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:
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.
Type or print name Title or Authority
Sign re Date
I, r/ , iii12127,1 , a Notary Public of the County of f6m.,94114-
State of - hereby certify that ,4C /--e /(.(V(/lil$AL appeared
personally before me this day and being Csk'ily sworn acknowledged that the above form was
executed by him. ;/ C,�
Witness my hand and notarial seal, this ';' day of , 20 e a/
Olfqii'd2/4)
Notary
Seal NATHAN G PABON /'-'��4�j J
Notary Public commission expires
State of Wisconsin