NCC243463_FRO Submitted_20241112

Check if this project is ARPA-funded El
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 NCG01 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 Alianza Goldsboro
*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).
2. Location of land-disturbing activity: County Wayne City or Township
Highway/Street SR 1895 (Gateway Dr) Latitude(decimal degrees)35.367075Longitude(decimaI degrees)-77.919682
3. Approximate date land-disturbing activity will commence: 10/1/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 16.13 acres
6. Amount of fee enclosed: $ 1700 . 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 ❑ No N
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ray Potts(Jackson Builders Inc) E-mail Address [e-mail]
Phone: Office# 919.734.5428 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
County of Wayne 919.731.1435 919.223.3559
Name Phone: Office# Mobile#
PO Box 227 224 E Walnut Street
Current Mailing Address Current Street Address
Goldsboro NC 27533 Goldsboro NC 27530
City State Zip City State Zip
10. Deed Book No. 1309 Page No. 867 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 fisted as the financially responsible party(ies).
Team Foods USA, Inc. [e-mail]
Company Name E-mail Address
6 Davis Drive, Suites 532 and 532A 6 Davis Drive, Suites 532 and 532A
Current Mailing Address Current Street Address
Durham NC 27709 Durham NC 27709
City State Zip City State Zip
Phone: Office# 305-301-0825 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:
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:
Cogency Global Inc. [e-mail]
Name of Registered Agent E-mail Address
2810 Coliseum Centre Drive, Ste 120 2810 Coliseum Centre Drive, Ste 120
Current Mailing Address Current Street Address
Charlotte NC 28217 Charlotte NC 28217
City State Zip City State Zip
Phone: Office# Mobile#
Sean Honan 866-621-3524
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.
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.
Donald Wesley Avera for Juan Sebastian Nino Director-Secretary
Type or print name Romero Title or Authority
Donald W. 10/8/2024
Signat e Date
I, I'fn. i� /��yCS / 94.5s01i« , a Notary Public of the County of Joiln-vi-y-A..•
State of North Carolina,hereby certify thaQnnu.lcI 1116tvi 111a0- 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 � y of AC I t0121( , 20.4
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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#

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.

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: Alianza Goldsboro
*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).
Is Project ARPA Funded ARPA Project Name ARPA Project#
No
2. Location of land-disturbing activity: County: Wayne City or Township: Goldsboro
Highway/Street: SR 1895 (Gateway Dr) Latitude: 35.367075 Longitude:-77.919682
3. Approximate date land-disturbing activity will commence: 10/1/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 16.13
6. 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).
7. Has an erosion and sediment control plan been filed? Yes-Will be Mailed or Hand-Delivered
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Ray Potts E-mail Address: [e-mail]
Phone: [phone] Mobile: [phone]
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
County of Wayne [e-mail] 919-731-1435
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
224 E Walnut St Goldsboro North 27530 PO Box 227 Goldsboro North 27530
Carolina Carolina

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).
Primary Financially Responsible Party
Company Name Email Business Phone Mobile Phone
Team Foods USA, Inc. [e-mail] 3053010825 8172019877
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
6 Davis Drive Durham NC 27709 6 Davis Drive Durham NC 27709
Additional Financially Responsible Parties
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:
Registered Agent Information
Name Email Business Phone Mobile Phone
Cogency Global Inc. - Sean Honan [e-mail] 8666213524
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
2810 Coliseum Charlotte NC 28217 2810 Coliseum Charlotte NC 28217
Centre Drive Centre Drive
(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:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
William G. Daniel &Associates, PA [e-mail] 919-467-9708 919-413-7477 _
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
1150 SE Maynard Cary NC 27511 1150 SE Maynard Cary NC 27511
Rd St 260 Rd St 260

Additional Details
1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water; NSW: Nutrient
Sensitive Waters
2. Was Express Review Requested: No
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.