NCC222107_FRO Submitted_20220607

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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 Quarity Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or %x information unavailable, place N/A in the blank.)
Part A.
Project Name Them oFisher Building 7 Parking Lot
Highway/Street Latitude 34*4254.7'N Longitude 76*596.6W
3. Approximate date land -disturbing activity will commence: 4/1122
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
6.
Amount of fee enclosed: $
200.00 'Tbe application fee of $65.00 per acre (rounded
up lo the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7.
Has an erosion and sediment control plan been filed? Yes No Enclosed X
8.
Person to contact should erosion
and sediment control issues arise during tand-disturbing activity:
Name___EhflftRIIndseyE-matl
Address Phillip.lindsey@thermoffsher com,
Telephone__
Cell # 25L-a3-6_72-�
9.
Landowner(s) of Record (attach accompanied page to fist addonal owners):
B209MM 99k$
2522QZaIM
Name
Telephone Fax Number
SM Moo LuhK Lgm ir H"
5900 MgM L&OW Kim Jr do
Current Mailing Address
CurTe� Street Address
gr_eenvdle N9
MM QM_nv*e N_C 27834
city State
zip City state ZIP
10.
Deed Book No. DB 3227
Page No. PG 435 — Provide a copy of the most current deed.
Part B.
I .
Person(s) or firm(s) who are
financially responsible for the land -disturbing activity (Provide a
comprehensive W of all responsible parties on an attached sheet):
Thermofisher Scientific
Name
E-mall Address
5900 Martin Luther Kjn-q Jr. Hwy 59M Martin Luther 12M Jr. Hwy
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville NC 27&U
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 AddnAps
Current Mailing Address Current Street Address
City State Zip city State zip
Telephone Fax Number
NIA
Name of Registered Agent
Current Mailing Address
TIM, ff-T
E-mail Address
Current Street Address
Telephone 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 inclividual
or his attorney -in -fact, or if not an individual, by an ofter, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected informiation should there by any change in the information provided herein.
ChOrm I WOMY 8r-. 51-A-F�
Type or print name Title or Authority
SignAture Date
1, a Notary Public of the County of
State of North Carolina, hereby certify that I' J rrk�p- C- appeared
personally before me this day and being duly sworn acknowledged th#t the above form was
executed by -him.
Witness my oomif han rial seat, this S"4day of lq& 20 g
Matt
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