NCC221951_FRO Submitted_20220531

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 N/A in the blank.)
Part A.
1. Project Name MegaSite Utility Construction Laydown
2. Location of land -disturbing activity: County GUILFORD/RANDOLPH City or Township Clay (GUI)/ Liberty (RAN)
8794 Old US 421 3s.ao3368
Highway/Street LatltUde(decimal degrees} Long ltUde(decimal degrees_
3. Approximate date land -disturbing activity will commence: May 20, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Construction (temorary)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.96
6. Amount of fee enclosed 5 600 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 ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Daniel Lynch E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Marjorie Beeson [phone] N/A
Name Phone: Office # Mobile #
5948 Macedonia Loop Road 5948 Macedonia Loop Road
Current Mailing Address Current Street Address
Liberty NC 27298 Liberty NC 27298
city State Zip City State Zip
003938/001318 01785/00919
10. Deed Book No-_ _ _ Page No. ' Provide a copy of the most current deed.

Part B.
3 . 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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Jimmy R Lynch & Sons, Inc,
Company Name
P.O. Drawer BB
Current Mailing Address
Pilot Mountain NC 27041
City State Zip
Phone: office # [phone]
[e-mail]
E-mail Address
314 S Academy St.
Current Street Address
Pilot Mountain NC 27041
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:
James Daniel Lynch
Namc of Registcred Agcnt
P.O. Drawer BB
Current Mailing Address
Pilot Mountain NC 27041
City State
Phone: Office # [phone]
[e-mail]
E-mail Address
314 S Academy St.
Current Street Address
Pilot Mountain NC 27041
Zip City
Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If -the -Financially Responsible Party is not a resident of North Carolina, give name and street address
szf-th�deaignatesl..North Car_nGn,a-agent_who_ia..registered..on..the.NC..Secretary..of..State.business.r_egistry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(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.
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.
James Daniel Lynch President
Type or rint a Title or Authority
Si atur Dat
I, a Notary Public of the County of 'Llh"
State of North Carolina, hereby certify thatLynp�, appeared personally
before me this day and being duly sworn acknowledged that the above fdrm was executed by him/her-
Witness my hand and notarial seal, this L• day of 20
Notary
[ph^ •---`.y»L.q--{�..-�-.�. My commission expireA,,
No ibry KNIc
Stale of North Carolkia
coun3 V o. Surry

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Marjorie Beeson 336) 622-2884 N/A
Name Phone: Office # Mobile #
5948 Macedonia Loop Road 5948 Macedonia Loop Road
Current Mailing Address Current Street Address
Liberty NC 27298 Liberty NC 27298
City State Zip City State Zip
Deed Book No. 003938 Page No. 001 785 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record -
Name
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record
Name
Current Mailing Address
City
Deed Book No.
Phone: Office #
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Mobile #
State. .Zip.. City gtaw Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
City
Phone: Office #
State Zip
State Zip
E-mail Address
Current Street Address
State Zip City State
Mobile #
Zip