NCC221500_FRO Submitted_20220418

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. Fiberon 3NL Expansion
1. Project Name
2.
3
Location of land -disturbing activity: County Stanly
Highway/Street US Hwy 52 Latitude 35.449
City or Township New London
Approximate date land -disturbing activity will commence. Jan 2022
Longitude, -80.234
4. Purpose of development (residential, commercial, industrial, institutional, etc.)- Industrial (expansion)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 5.7 Acres
6. Amount of fee enclosed: 5 600 . 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:
Nance Gaius Carter E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Fiber Composites LLC 704-463-7120
Name
44017 US Hwy 52
Current Mailing Address
New London, NC, 28127
City State
10. Deed Book No. 1671
Telephone
44017 US Hwy 52
Current Street Address
New London, NC 28127
Zip City
Page No. 1211
State
Fax Number
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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Fiber Composites LLC [e-mail]
Name E-mail Address
44017 US Hwy 52 44017 US Hwy 52
Current Mailing Address Current Street Address
New London, NC, 28127 New London, NC, 28127
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
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:
Corporation Service Company
Name of Registered Agent
2626 Glenwood Ave Ste 550
Current Mailing Address
Raleigh, NC 27608
City State
Telephone
E-mail Address
2626 Glenwood Ave Ste 550
Current Street Address
Raleigh, NC 27608
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.
Mike Miller
Type or p nt me
igna ure
4 i / 201
Title or Authority
3 2©Z7 _
Date
1, KaLam► Pr I a Notary Public of the County of
State of North Carolina, hereby certify that 1 JAaj3IN1 � 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 Mjj Irr,n 20 a
d' _atbai�_
Notary
Seal
My commission expires-6-- 12. d Ua