NCC221328_FRO Submitted_20220407

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
1. Project Name ROANOKE VALLEY LUMBER
2. Location of land -disturbing activity: County — HALIFAX Township WELDON
Highway/Street: 290 Power Place, Weldon, NC 27890
Approximate date land -disturbing activity will commence: March 31, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_INDUSTRIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 42 ACRES
6. Amount of fee enclosed: $6.200.00 ($4,200.00 for the normal fee and $2,000 for the supplemental fee).
The Express Permitting application fee is a dual charge. The normal fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount. In addition, the Express Permitting
supplement is $250.00 per acre up to eight acres, after which the Express permitting supplemental fee
is a fixed $2,000.00 (Example: 9 acres total is $2,900).
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:
Nick Whitehead, PE
Roseburg
Structural Products Engineering Manager
Ph: 541.679.2106
Cell: 971.701.3152
[e-mail]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Roseburg South Lumber, LLC
3660 Gateway Street
Springfield, OR 97477
10. Deed Book No. 2690 Page No. 136 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.
Roseburg South Lumber, LLC
3660 Gateway Street
Springfield, OR 97477
Attn: Matt Lawless, Asst. General Counsel and Secretary
Ph: 541.658.6149
Fax: [phone]
Email: [e-mail]

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:
Roseburg South Lumber, LLC
160 Mine Lake Ct Ste 200
Raleigh, NC 27615
(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:
Roseburg South Lumber, LLC
160 Mine Lake Ct Ste 200
Raleigh, NC 27615
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Nick Whitehead, PE
Roseburg
Structural Products Engineering Manager
Ph: 541.679.2106
Cell: 971.701.3152
[e-mail]
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.
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Signature
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Title or Authority
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Date
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a Notary Public of the County of Lane,
State of Oregon, hereby certify that Matthew M. Lawless 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 ch, 0�
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Notary 1
OFFICIAL STAMP .
LORI LYN HEALER NOTARY PUBLIC - OREGON My commission expires J �+
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COMMISSION NO. 1004639
MY COMMISSION EXPIRES OCTOBER 06, 2024