NCC221678_FRO Submitted_20220504

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Linder Greensboro
2. Location of land -disturbing activity: County Guilford City or Township Greensboro
1299 Youngs Mill Road 36.0561-79,7067
Highway/Street Latitude{aecima�degrees} Long itude(decimaldegrees)
3. Approximate date land -disturbing activity will commence: 5/2/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12
6. Amount of fee enclosed: $ 100.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJarred Blanton E-mail Address [e-mail]
Phone: Office # 828-324-1284 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Linder Industrial Machinery Company 919-698-2704
Name Phone: Office # Mobile #
1601 S. Frontage Road 1601 S. Frontage Road
Current Mailing Address Current Street Address
Plant City, FL, 33563 Plant City, FL, 33563
City State Zip City State Zip
10. Deed Book No. 008483 Page No. 02722 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
David E. Looper & Company
Company Name
PO Box 3224
Current Mailing Address
Hickory, NC 28603
City State Zip
Phone: Office # 828-324-1284
[e-mail]
E-mail Address
320 15th Street SE
Current Street Address
Hickory, NC 28602
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Brian Walker
Name of Registered Agent
PO Box 3224
Current Mailing Address
Hickory, NC, 28603
City State
Phone: Office # 828-324-1284
[e-mail]
E-mail Address
320 15th Street SE
Current Street Address
Hickory, NC, 28602
Zip City State Zip
Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
NA
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. if the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
ZVI
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
,
Type or print name
Signature
V O C044C 1- G
Title or Authority
L2, <.
Date
a Notary Public of the County of RIACkq
State of North Carolina, hereby certify that Erin n Uaiker appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this aj h day of T1 20qD_
LISA R LINGLB P
Notary Public, North Carolina 94
Notar
Burke County
My C&nmisslon Expires f
January 01 2026 My commission expires . 1 , a 1)1z)