NCC221296_FRO Submitted_20220405

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 NIA in the blank.)
Part A. mes Novoz discharge i eline/residuals tank
1. Project Name Y g p p
2. Location of land -disturbing activity: County Franklin City or Township
Highway/Street Perrys chapel church Rd.JNc tivur 56 Latitude start: 11.0725 end: 36A017' Longitude start: 78.38944 end: 78.40787
3. Approximate date land -disturbing activity will commence: 2/14/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 18
6. Amount of fee enclosed: $ 1800 . 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 Randy Green
E-mail Address rwgr p0novozymes.com
Telephone [phone] cell # 919-495-1492 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Novozymes North America, Inc.
919-494-3000
Name
Telephone Fax Number
P.O. Box 576
77 Perrys Chapel Church Rd,
Current Mailing Address
Current Street Address
Franklinton, NC 27525
Franklinton, NC 27525
City State Zip
City State Zip
10, Deed Book No. 765 Page No. 355 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.
Novozymes North America, Inc.
Name
E-mail Address
P.O. Box 576
77 Perrys Chapel Church Rd.
Current Mailing Address
Current Street Address
Franklinton, NC 27525
Franklinton, NC 27525
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:
CT Corporation System
Name of Registered Agent
160 Mine Lake Ct, Suite 200
Current Mailing Address
Raleigh, NC 27615-6417
City State Zip
Telephone [phone]
E-mail Address
160 Mine Lake Ct, Suite 200
Current Street Address
Raleigh, NC 27615-6417
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.
Type or print Aame Title or Authority
Signature Date
I, '-�i� • � On rl e _ , a Notary Public of the County ofi`Q-r�i(
State of North Carolina, hereby certify that �rc�c��e�F'�L . Col>- 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 J � day of�G�n� _, 20 Q D
Notary
AffkYLA. DUNNE
NOTARY PUBLIC My commission expires.
FRANKLIN COUNTY, NC
'y Commission Expires 9-26-2025