NCC216985_FRO Submitted_20220106

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 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 thee -mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Louisburg Annex
1. Project Name
Franklin cit or Louisburg
2. Location of land -disturbing activity: County Y p
Highway/Street Retail Way Latitude 36.08181 Longitude -78.31915
3. Approximate date land -disturbing activity will commence:
Late 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):industrial_
2.60 ac original +
5. Total acreage disturbed or uncovered ((�including off -site borrow and waste areas):. 0.40 ac additional
$195.08 original
6. Amount of fee enclosed: $ + $0 additional The application fee of $65.06 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
John Church E-mail Address][e-mail]
Telephone [phone] —Cell # 9198186904 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Louis OP LLC 9194015500 9194015501
Name Telephone Fax Number
6350 Quadrangle Dr. Ste. 205
Current Mailing Address Current Street Address
Chapel Hill NC 27517
city State Zip City State Zip
10. Deed Book No. 1 725 Page No. 500 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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Louis OP LLC [e-mail]
Name E-mail Address
6350 Quadrangle Dr. Ste. 205
Current Mailing Address Current Street Address
Chapel Hill NC 27517
City State Zip City State Zip
Fax Number 9194015501
Telephone [phone]

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Gilbert Laite [e-mail]
Name of Registered Agent E-mail Address
301 Fayetteville Street, Suite 1700
Current Mailing Address Current Street Address
Raleigh, NC 27601
City State Zip City State Zip
Telephone [phone] Fax Number 9199814300
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.
John Church Member
Ty or prin nam Title or Authority
7/1 /21
Si n ture Date
I, AP es � (zfLe rle , a Notary Public of the County of cV jli e
State of North Carolina, hereby certify that Sc){6 n co 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 l day of To / L, 20.000 �
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N O - Notary
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CD ? My commission expires s / 7 -
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