NCG140454 - McCarthy Warren County Concrete Batch Plant

TERRA
CONSULTING
June 12, 2017
NC Dept of Environmental Quality
JUN 15 2017
Stormwater Permitting Unit Program
Division of Energy, Mineral and Land Resources Raleigh Regional Office
1612 Mail Service Center
Raleigh, NC 27699-1612
Plan Reviewer:
The enclosed Notice of Intent and site plan are being submitted on behalf of McCarthy Improvement
Company for the operation of a proposed portable concrete batch plant to be located at 1224 Ridgeway
Drewry Road, Manson in Warren County. The following documents have been enclosed:
Check for application fee of $100.00;
Completed Notice of Intent;
Two (2) sets of the Site Plan (including vicinity map); and
One (1) copy of Financial Responsibility form as evidence of Erosion and Sedimentation Control
Plan submittal.
McCarthy Improvement is contractual obligate to begin paving from this site July 15, 2017.
If you have any questions or require additional information please contact me at [phone] or
[e-mail].
Thank you,
e -A -c-
Jacki Congleton
Terra Consulting, LLC
Enclosures
CC: Kevin Crusa, McCarthy Improvement Company
Terra Consulting, LLC • P.O. Box 1738 • Carrollton, GA 30112 • 770-573-3055 • www.terraconsultingllc.com

AL- '
NCDENR
NORTH CAROLINA CERARTMENT OF
ENVIRONMENT AND Nq RAL RESOURCE;
NOTICE OF INTENT
Division of Energy, Mineral and Land Resources
Land Quality Section
National Pollutant Discharge Elimination System
NCG140000
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
Certificate ofCoverage
NICIGI 11410141
Check # AA owit
ba�
71
cto
�
Pcrm t Assn ied to
ba�
71
.
77
National Pollutant Discharge Elimination System application for coverage under General Permit o•
NCG140000:
STORMWATER AND PROCESS WASTEWATER DISCHARGES associated with activities classified as: O
SIC (Standard Industrial Classification) Code: 3273 and like activities - Ready Mixed Concr(e
(1)
This NOI may be an application to discharge process wastewater. NCG140000 contains effluent limitations
for process wastewater discharges. Wastewater discharges must meet the requirements of these
effluent limitations. An exceedence of any of these limitations will result in a violation of the permit
conditions.
For questions, please contact the DEMLR Central Office or Regional Office in your area. (See page 6)
(Please print or type)
1) Mailing address of owner/operator (official address to which all permit correspondence will be
mailed): (Please print or type all entries in this application form.)
Legal Owner Name McCarthy Improvement Company
(Please attach the most recent Annual Report to the NC Secretary of State showing the current legal name. Alternatively this
permit can be given to an individual.)
Signee's Name (as signed for in question 29 below) Kevin Crusa
Street Address 590 Means Street NW
City Atlanta State GA_ ZIP Code 30318
Telephone No 864-630-0314 Email kcrusa(d,)mccarthylmprovement com
Alternate Contact Name Steve Button email (if different) [e-mail]
Alternate Contact Telephone (if different) [phone]
2) Location of facility producing discharge:
Facility Name McCarthy Warren County Concrete Batch Plant
Facility Contact Kevin Crusa, Project Manager
Street Address 1224 Ridgeway Drewry Road
City Manson State NC _ ZIP Code 27553
County Warren County
Telephone No. 864 — 630-0314 Fax NA
3) Physical location information:
Please provide narrative directions to the facility (use street names, state road numbers, and distance and
direction from a roadway intersection) From Raleigh travel north on Interstate Highway 85 (1-85) to exit 226
Ridgeway -Drewry Road turn left (west) travel for approximately 0 2 mile to the construction entrance on the
right
(A copy of a county map or USGS quad sheet with facility clearly located on the map is a required part of this application )
4) Latitude 36° 27' 22.18" Longitude -780 16' 05.05" (deg, min, sec)
5) This NPDES Permit Application applies to the following (check all that apply):
R1 New or Proposed Facility Date operation is to begin August 1, 2017
❑ Existing Facility
SWU-229-11032011
Permit #
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NCG140000 N.O.I.
6) Consultant's application information:
Consultant: Jacki Conaleton
Consulting Firm
Mailing Address
City. Car
State: G,
Zip Code -
Phone- ( 770) 573-3055 Fax ( )
Email -
(Optional)
Staple Business Card Here:
7) Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary
industrial activity at this facility:
SIC Code. 3 2 7 3
8) Provide a brief description of the types of industrial activities and products produced at this facility:
(Attach a site diagram showing the process areas present at this facility.)
See attachment A
Stormwater Discharge, Wastewater Treatment & Discharge and Permitting Information
9) Discharge points / Receiving waters:
Number of discharge points (ditches, pipes, channels, etc.) that convey stormwater and/or wastewater from
the property
Stormwater-only: _0 Wastewater -only: _0 Wastewater Commingled with Stormwater. 1
For new facilities, Expected date of commencement of discharge: August 1, 2017
What is the name of the body or bodies of water (creek, stream, river, lake, etc ) that the facility stormwater
and/or wastewater discharges end up in? Smith Creek
Receiving water classification (s), if known. C
If the site stormwater discharges to a separate storm sewer system, name the operator of the separate storm
sewer system (e g City of Raleigh municipal storm sewer). NA
Will this facility discharge wastewater to SA (Shellfishing) waters? ❑ Yes Q No
Note: Discharge of process wastewater to receiving waters classified as WS -II to WS -V or SA must
be approved by the N.C. Division of Water Resources, Public Water Supply Section. If DWR
does not approve, coverage under NCG140000 cannot be granted. No new discharges of
process wastewater are permitted in receiving waters classified as WS -1 or freshwater ORW.
10) Each applicant shall provide the following information (attach additional sheets as necessary):
• Two (2) site plans depicting the facility or site with numbered outfalls which indicate stormwater and
wastewater outfalls. The plans shall legibly show. at a minimum, (existing or proposed):
o Outline of drainage areas with topographical lines and features
o Stormwater/wastewater treatment structures
o Location of numbered stormwater/wastewater outfalls (corresponding to which drainage areas)
o Runoff conveyance structures
o Areas and acreage where materials are stored
o Impervious area acreages
o Location(s) of streams and/or wetlands the site is draining to, and any applicable buffers
o Site property lines, North Arrow, and bar scale
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NCG140000 N.O.I.
o If applicable, the 100 -year floodplain line
o Acreage of each stormwater and wastewater topographical area
o Each of the facilities' wastewater or stormwater source and discharge structures and each of its
hazardous waste treatment, storage, or disposal facilities
o Site location (insert)
Site plans shall be 24" x 36" in size.
• Line drawing and description: A line drawing of the water flow through the facility A pictorial
description of the nature and amount of any sources of water and any collection and treatment measures.
• A narrative description and identification of each type of process, operation, or production area which
contributes wastewater to the effluent for each outfall, and a description of the treatment the wastewater
receives (or will receive), including the ultimate disposal of any solid or fluid wastes other than by
discharge. Processes, operations, or production areas may be described in general terms (e g. "ash
silo").
11) Does the applicant have any unresolved Notice of Violations (NOVs)?
Q No ❑ Yes
Wastewater.
12) What types of wastewater does your facility generate or discharge?
Type of Authorized Wastewater
Generate
Discharge
Sent to WW
Treatment
System
Vehicle and equipment cleaning (VE)
Q
Q
❑
Wetting of raw material stockpiles (RM)
Q
Q
❑
Mixing drum cleaning (MD)
Q
Q
❑
Further explanation, if necessary See Attachment A
13) Will your facility spray -down or actively wet aggregate piles?
❑ No Q Yes
14) Does the facility use any of the following on site?
❑ Phosphorus -containing Detergents
❑ Brighteners ❑ Other Cleaning Agents
❑ Non -Phosphorus -containing Detergents
❑ Other:
15) Are wastewater treatment facilities planned in the 100 -year flood plain?
Q No ❑ Yes
16) Does your facility use or plan to use a recycle system, or recycle components in your treatment system?
Q Yes ❑ No
If yes, what size storm event is the system designed to hold before overflowing? (for example, 10 -yr, 24 -hr)
10 year
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NCG140000 N.O.I.
,_17) Will your facility build a closed-loop recycle system that meets design requirements in 95A NCAC 02T
i 1000 and hold your facilities' working volume'?
❑ Yes Q No
Will your facility discharge wastewater to surface waters?
R1 Yes ❑ No
If the facility's treatment system meets the design requirements of 15A NCACO2T .1000 (including holding
the 25 -year, 24-hour storm plus one foot of freeboard), holds the working volume of your site, and does
not discharge wastewater to surface waters, you may not be required to obtain an NPDES permit for
wastewater discharges. If you believe this is the case, please contact DEMLR's Aquifer Protection Section
Land Application Unit Central Office Supervisor or staff (1636 Mail Service Center, Raleigh, NC 27699-1636)
for more information on obtaining the necessary permits or approvals. If you will discharge wastewater or
stormwater to surface waters, please continue to apply for a permit to discharge associated with ready -mixed
concrete or like operations under NCG140000. For further questions, please contact DEMLR's Stormwater
Permitting Unit Staff.
18) A wastewater treatment alternatives review is required by 15A NCAC 2H 0105 (c)(2) for any new or
expanding water pollution control facility's discharge in North Carolina. You may attach additional sheets
a) What wastewaters were considered for this alternatives review? RIVE Q RM OMD
b) Connection to a Municipal or Regional Sewer Collection System:
I) Are there existing sewer lines within a one -mile radius? .. ❑ Yes R1 No
(1) If Yes, will the wastewater treatment plant (WWTP) accept the wastewater? .... ❑ Yes ❑ No
(a) If No, please attach a letter documenting that the WWTP will not accept the wastewater
(b) If Yes, is it feasible to connect to the WWTP? Why or why not?*
c) Closed-loop Recycle System (must meet design requirements of 15A NCAC 2T.1000):
Are you already proposing a closed-loop recycle system (CLRS)? ❑ Yes Q No
(1) If Yes, contact DEMLR's Aquifer Protection Section's Land Application Unit
(2) If No, Is this option technologically feasible (possible)? Why or why not?*
see attachment A
(3) If No, is it feasible to build a CLRS on your site? Why or why not?*
see attachment A
(4) What Is the feasibility of building a CLRS compared to direct surface water discharge?*
see attachment A
1 See DWQ's Aquifer Protection Section Land Application Unit's Water Balance Calculation Policy for more information, on DWQ LAU's
website http //portal ncdenr org/web/wa/aps/lau/policies for more information
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NCG140000 N.O.I.
d) Surface or Subsurface Disposal System (e.g., spray irrigation):
i) Is a surface or subsurface disposal technologically feasible (possible)? ....................Q Yes ❑ No
Why or Why not? See attachment A
ii) Is a surface or subsurface disposal system feasible to implement?" .....................
Why or Why not?
See attachment A
Q Yes ❑ No
iii) What is the feasibility of employing a subsurface or surface discharge as compared to a direct
discharge to surface waters?* See attachment
e) Direct Discharge to Surface Waters: Is discharge to surface waters the most environmentally sound
alternative of all reasonably cost-effective options of the wastewaters being considered?*... Q Yes ❑ No
J) If No, contact DEMLR's Land Application Unit to determine permitting requirements.
f) If this review included all wastewater discharge types, would excluding some types (e.g. raw
stockpile wetting) make any of the above non -discharge options feasible? .............. ❑ Yes Q No
* You may be asked to provide further information to support your answers to these questions after the initial review.
Feasibility should take into account initial and recurring costs.
Stormwater:
19) Does this facility employ any best management practices for Stormwater control? ❑ No Q Yes
If yes, please briefly describe: See Attachment A
20) Does this facility have a Stormwater Pollution Prevention Plan? ❑ No 21 Yes
If yes, when was it implemented? The SPPP will be completely implemented before the commencement of
operations
21) Are vehicle maintenance activities (VMA) occurring or planned at this facility? Q No ❑Yes
If yes, does your VMA area discharge into your wastewater treatment device? ❑ No ❑ Yes
Other/Permitting:
22) Does this facility have a Division of Land Resources Erosion & Sedimentation Control (E&SC) Permit?
❑ No Q Yes
If yes, list the permit numbers for all current E&SC permits for this facility: NCG 0100000
23) Is your facility subject to Phase II Post -Construction Area? ❑ Yes
If yes, who is the permitting authority?
Z No
24) Is your facility located in one of the 20 Coastal Counties? ❑ Yes Z No
Is your facility adding more than 10,000 ft2 of built -upon area or CAMA Major Permit? ❑ Yes Q No
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NCG140000 N.O.I.
25) Is your facility discharging wastewater (treated or untreated) such as water from wetting of aggregate piles,
drum rinse -out, or vehicle and equipment cleaning to a stormwater BMP? ❑ No Q Yes
If yes, please attach your approval from the permitting authority to do so
26) Does this facility have any other NPDES permits? ❑ No R1 Yes
If yes, list the permit numbers for all current NPDES permits for this facility: NCGO100000 applied for
27) Does this facility have any Non -Discharge permits (ex: recycle permits)? Q No ❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility.
28) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
Q No ❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
Q No []Yes
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
R1 No ❑ Yes
d) Type(s) of waste: used oil
How is material stored. in one (1) 75 -gallon self contained double wall plastic tank
Where is material stored- in tank near the parts trailer
How many disposal shipments per year: one 1
Name of transport / disposal vendor Safety-Kleen
Vendor address: 6225 Old Stage Road, Raleigh, NC 27603
Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
Q Check for $100 made payable to NCDENR
Q This completed application and all supporting documentation. See Question 10.
1t If an Erosion & Sedimentation Control (E&SC) Plan is required from Division of Land Resources (DLR)
or local designee documentation verifying applicant has developed and submitted that Plan to the
governing agency (required per 15A NCAC 02H .0138)
Two (2) site plans depicting the site plan with numbered outfalls which Indicate stormwater and wastewater
1 outfalls. See Question 10.
Q A county map or USGS quad sheet with location of facility clearly marked.
29) Signatory Requirements (per 40 CFR 122.22)
All applications, reports, or information submitted to the Director shall be signed and certified
a All notices of intent to be covered under this General Permit shall be signed as follows
(1) For a corporation by a responsible corporate officer For the purpose of this permit, a responsible corporate officer means. (a) a president,
secretary, treasurer or vice president of the corporation in charge of a principal business function, or any other person who performs similar
policy or decision making functions for the corporation, or (b) the manager of one or more manufacturing production or operating facilities
employing more than 250 persons or having gross annual sales or expenditures exceeding 25 million (in second quarter 1980 dollars), if
authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures
(2) For a partnership or sole proprietorship. by a general partner or the proprietor, respectively, or
(3) For a municipality, state, federal, or other public agency: by either a principal executive officer or ranking elected official
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NCG140000 N.0.1.
Certification: North Carolina General Statute 143-215.6 B(i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document
filed or required to be maintained under this Article or a rule implementing this Article, or who knowingly makes a false statement of a material
fact in a rulemaking proceeding or contested case under this Article, or who falsifies, tampers with, or knowingly renders inaccurate any recording
or monitoring device or method required to be operated or maintained under this Article or rules of the [Environmental Management] Commission
implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000)
I hereby request coverage under the referenced General Permit I understand that coverage under this permit will
constitute the permit requirements for the discharge(s) and Is enforceable in the same manner as an individual
permit.
I certify that I am familiar with the Information contained In this application and that to the best of my knowledge
and belief such information is true, complete, and accurate.
Printed Name of Person Signing: Kevin Crusa
Title.
of Applicant)
d1l 2017
(Date Signed)
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to: NCDENR
Mail the entire package to:
Stormwater Permitting Unit Program
Division of Energy, Mineral and Land Resources
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Note
The submission of this document does not guarantee the issuance of an NPDES permit.
For questions, please contact the DEMLR Regional Office for your area.
DEMLR Regional Office Contact Information:
Asheville Office .
Fayetteville Office
Mooresville Office
Raleigh Office ...
Washington Office
Wilmington Office
Winston-Salem
Central Office .....
[phone]
[phone]
[phone]
[phone]
[phone]
[phone]
[phone]
... [phone]
Page 7 of 7
SWU-229-07122011 Last revised 7/2/14

Attachment A
NCG140000 N.O.I. Additional Information for Questions
McCarthy Improvement Company, Inc.
McCarthy Warren County Concrete Batch Plant
8) Description of Industrial Activities
The facility will be a temporary concrete batch plant located on a 4.39 acre parcel leased by McCarthy
Improvement Company located near the intersection of Interstate Highway 85 and Ridgeway Drewry Road in
Warren County. The site was previously undeveloped pasture land. The McCarthy Improvement plant will
provide the concrete for a repaving project in Interstate Highway 85.
12) Type of Wastewater
A combination of wastewater and stormwater will be discharged from this facility's outfall intermittently during
the 18 months the plant is expected to be located at this site. Wastewater will be comingled with stormwater only
when the plant is in operation. The plant will operate intermittently during the 18 month on site. On the days the
plant is operating the wastewater described in Attachment B will be generated.
16) Recycling system
This plant will be using a series of three settling pits to treat and recycle the washout water from the truck bed
washout area. The plant anticipates approximately 200 washouts per day. Each washout will use approximately
50 gallons of water. The anticipated volume of wash water generated will be approximately 10,000 gallons per
day, which will be contained and recycled through the settling pits. The total holding capacity of the settling pits
will be approximately 90,000 gallons. The waste water from the third pit will be recycled as washout water and
used for dust suppression on the vehicle travel routes on the site. Eighteen inches of freeboard will be maintained
in the third washout pit to accommodate a 10 year rain (5.7 inches) event over the three ponds.
18) Wastewater Treatment Alternatives Review
c) Closed-loop Recycling System (15A NCAC 2T.1000)
(2) Construction of a CLRS meeting NC standards 15A NCAC 2T .1000 is not technologically feasible.
The small size of the site does not provide the space necessary to construct the CLRS to meet the NC
standards.
(3) The plant will be located at this site for approximately 18 months. The limited operational time at the
site does not justify the expense of constructing the CLRS. Additionally, this project, as with most
similar projects, has a fairly short lead time and the six months or more that would be necessary for the
design, approval, and installation of a CLRS is not available.
(4) The time and disruption of constructed infrastructure required for the design, approval, and
installation of a closed-loop recycling system that will be utilized for the treatment of a limited amount of
wastewater the next 18 months cannot be justified.
(d) Surface or Subsurface Disposal Systems
(i) Wastewater from the recycling system can be used for dust suppression and a skimmer basin will
reduce solids in the water discharged to the surface.
(ii) Water from the recycling system described in Question 16 will be used for dust suppression when the
residual suspended solids in the water make it impossible to continue recycling the water. Also, all
wastewater will be contained within a skimmer basin which will allow a significant portion of the
suspended solids to settle out before being discharged to the surface.
(iii) Both methods of surface disposal are feasible and will be implemented.

19) Best Management Practices (BMP)
(1) Perimeter containment/diversionary berms and a drainage swale will direct the combined stormwater and
wastewater discharges to the skimmer basin.
(2) A skimmer basin at the east end of the site will contain the combined stormwater and wastewater to allow a
significant portion of the suspended solids to settle out of the water before being discharged.
(4) All disturbed surfaces within the site boundaries will be stabilized with 4 to 6 inches of graded aggregate base
(GAB) or vegetated with permanent vegetation.
(5) All parts and maintenance oil, grease, and fluids will be stored inside the parts trailer at all times.
(6) Diesel fuel kept on site to fuel material handling equipment will be stored in a 1,000 gallon double-wall tank
and used oil from minor maintenance is stored in a 75 -gallon double-wall tank.
2

Attachment B — Description of Processes Producing Wastewater
Three processes at this facility will potentially contribute wastewater to the effluent from the outfall.
Wastewater Source 1:
Wastewater Source 1 is the concrete batch plant drum. The drum on the plant will be washed out once
per day on days he plant is operational. The wastewater produced from each washout is approximately
800 gallons per day.
Wastewater Source 2:
Wastewater Source 2 is the truck bed washout used to washout the beds of the dump trucks used to
transport the concrete to the location being paved. The plant anticipates producing 200 truckloads per
day and the trucks will be washed out after each trip. Each washout will use approximately 50 gallons of
water. The anticipated volume of wash water generated will be approximately 10,000 gallons per day,
which will be contained and recycled through a series of three pits designed to allow suspended particles
to settle out of the wash water. The combined holding capacity of the pits is approximately 90,000
gallons. The water in the third pit will be recycled as wash water or used for dust suppression on the site.
Solids will be removed from the pits when they occupy one half of the designed holding capacity of the
pit. The solids are dried and properly disposed of. Wastewater spilled or leaked from the recycling
system or the washout area would flow to the skimmer basin and ultimately be discharged to the surface.
Eighteen inches of freeboard will be maintained in the third washout pit to accommodate a 10 year rain
(5.7 inches) event over the three ponds.
Wastewater Source 3:
Wastewater Source 3 includes the aggregate and sand stockpiles. The aggregate stockpile will be wetted
using a lawn sprinkler and hose. The sprinkler will be rotated around the stockpile during the day to
cover all parts of the pile. Wetting the aggregate stockpile is done to produce an evaporative cooling of
the stone. The evaporation of the water during this sprinkling process reduces the volume of water that
ultimately flows away from the stockpile. Wetting is not used on the sand stockpile. Per DOT
specifications both the aggregate and sand are washed prior to being delivered to the site, reducing the
potential fines in stormwater runoff from the area covered by the stockpiles. Wetting of the aggregate
stockpile will be conducted up to 24 hours per day when the plant is operating. The wastewater from the
aggregate stockpile will consist of water from the wetting of the stone and stormwater that falls on the
pile. Wastewater from the sand stockpile will consist of only stormwater that falls on the pile.
Stormwater and wastewater from both stockpiles will flow to the skimmer basin and ultimately be
discharged to the surface.

NC Dept of Environmental Quality
JUN 15 2017
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT Raleigh Regional Office
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 Land
Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name /L1� C�Idf�1� LIT,} oti��fP(� �tle �C>° II��lGl/o Gy�/lw f1/�C
2. Location of land -disturbing activity: County WAd h$e) City or TownshipdgA Q4
HighwaylStreetf,,'Sm hit-�o.euJfiYlj Latitude 11{314,11X6dh Longitude (.) -if 26407
3. Approximate date land -disturbing activity will commence: fly 4 7,010' A
4. Purpose of development (residential, commercial, industrial, institutional, etc.):. aK.f14;01
a�4�0_w)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): el. 3f -.4g
6. Amount of fee enclosed: $ . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9 -acre application fee is $585).
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 &Vk A E-mail Address �_.nV_c If I
TelephoneG �/• 63a -O 3/y Cell # BY -03/ Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
4i1?� idf Ad 717-,7.V sr., W/W
.Name T Telephone Fax Number
14 'A earaa9 12.4 SA we-
Current
e -Current Mailing Address Current Street Address
11j112,: -e4 c/ L 7603
City State Zip City
State
Zip
10. Deed Book No. 37 Page No. 3r7 Provide a copy of the most current deed.
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):
McCarthy Improvement Comnanv info(@mccartliyimprovoinent.com
mccartiiyimprovement.com
Name E-mail Address
590 Means Street. NW. Suite 100
Current Mailing Address
Atlanta GA 30318_
City State Zip
same
Current Street Address
City State _ Zip
Telephone 404-68¢2ok4 Fax Number 404-761-4764

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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(b) If the Financially Responsible Parry 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:
Corporation Service Company
Name of Registered Agent
327 Hillsborough Street
Current Mailing Address
compliancemail(@,,cscglobal.com
E-mail Address
327 Hillsborough Street
Current Street Address
Raleigh, NC 27603 Raleigh, NC 27603
City State Zip City State Zip
Telephone [phone] Fax Number 850-555-1515
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 attomey-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.
Sonia L. Sundstedt
Type or print name
ignature
Corporate Secretary
Title or Authority
5/11/17
Date
I, FY4n1,e5 deo , a Notary Public of the County of seai
1ew6-
State of North -Carolina, hereby certify that �o^`°` Su^dS+ed.� appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this day of M(AV 20 1 �7
I�
Notary
Seal
My commission expires Ik (, i a b I'7
FRANCES M. COOK
Commission Number 793600
My Commission Expires
ow December 15, 2017