NCC216350_FRO Submitted_20211118

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Jarco Industrial Spec Building
1. Project Name p g
2. Location of land -disturbing activity: County Granville City or Township Butner
Highway/Street E Lyon Station Road Latitude 36.120321 Longitude-78.727774
3. Approximate date land -disturbing activity will commence: May 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 1.98 AC
6. Amount of fee enclosed: $ 1 30.00 . 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 x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad Abbott Email [e-mail]
Telephone,
Cell # 919-625-7368 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jarco Properties, LLC 919-669-1201
Name
100 Ag Drive
Current Mailing Address
Youngsville NC
Telephone
100 Ag Drive
Current Street Address
27596 Youngsville NC
City State Zip City
10. Deed Book No. 1 621 Page No. 479
State
Fax Number
27596
Zip
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company orfrrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Jarco Properties, LLC [e-mail]
Name E-mail Address
100 Ag Drive 100 Ag Drive
Current Mailing Address Current Street Address
Youngsville NC 27596 Youngsville NC 27596
City State
Telephone [phone]
Zip City
Fax Number
State
Zip

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
Telephone
E-mail Address
Current Street Address
State zip City State Zip
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Matt Jarrell
Type or print name
7tk'- err /_ QA&'-"& _
Signature
Managing Member
Title or Authority
04/22/20
Date
I, Mari { P Med l ire , a Notary Public of the County of Fr 1<l i n
State of North Carolina, hereby certify that Ma ltti w L . J a r re I I 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 AQr 1 I , 20 2O
r
MAR! P MEDLiN �M`P �� '
Notary
TARY PUBLIC
A% KLIN COUNTY, NC My commission expires 12/5I2020