NCC217029_FRO Submitted_20220107

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 the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Pureflow
1. Project Name
2. Location of land -disturbing activity: CountyAlamance City or Township Graham
Highway/Street Jay Lane Latitude 36.071 Longitude-79.366
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 1.1 Acres
6. Amount of fee enclosed: $ 780.00 . 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 Scott Flanagan E-mail Address [e-mail]
Telephone cell # 336-627-7700 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
D & L Land Development Co., LLC 336-532-0300
Name Telephone Fax Number
1241 Jay Lane 1241 Jay Lane
Current Mailing Address Current Street Address
Graham NC 27253-2615 Graham NC 27253-2615
City State Zip City State Zip
10. Deed Book No. 2021 Page No. 707 Provide a copy of the most current deed.
Part B. DB 1802 PG 44
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.
D & L Land Development Co., LLC & Pureflow, Inc. [e-mail]
Name E-mail Address
1241 Jay Lane 1241 Jay Lane
Current Mailing Address Current Street Address
Graham NC 27253-2615 Graham NC 27253-2615
City State Zip City State Zip
Telephone [phone] Fax Number

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. -
Daniel Johnson [e-mail]
Name of Registered Agent E-mail Address
1241 Jay Lane 1241 Jay Lane
Current Mailing Address Current Street Address
Graham NC 27253 Graham NC 27253
City State Zip City State Zip
Telephone [phone] 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.
Daniel J. Johnson
Typgigr print rye
nature
Manager
Title or Authority
10/22/2021
Date
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��. I, ( -k a Notary Public of the County of�a s IPo
State of North Carolina, hereby certify that Daniel J.
personally before me this day and being duly sworn
executed by him.
Johnson appeared
acknowledged that the above form was
Witness my hand and notarial seal, this 22 day of October
. 2021
US
A K HALL
NOTARY PUBLIC Notary
GUjj9RD COUNTY, NC
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