NCC222184_FRO Submitted_20220613

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 typo 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 NameNorth Carolina State Labrotory of Public Health
2. Location of land -disturbing activity: CountyWake City or TownshipRaleigh
4312 district drive 35.4828-78.4306
Highway/Street Latltude(decimal degrees) LOngltude{decimal degrees?
3. Approximate date land -disturbing activity will commence:6/6/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial addition
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.28
6. Amount of fee enclosed: $ 200.00 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 N Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address
Ben Mathison [e-mail]
Phone: Office # 336--333-2872 Mobile [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NC Department of Health and Human Services 919-855`41 00
Name Phone: Office # Mobile 4
2001 Mail Service Center 4312 District Drive
Current Mailing Address Current Street Address
Raleigh, NC 27699 Raleigh, NC 27607
City State zip City
State Zip
10. Deed Book No.01 7183 Page No. 02086 Provide a copy of the most current deed.

Part B.
1. Company(les) 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 arif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
The Christman Company
Company Name
408 South Elm Street
Current Mailing Address
Greensboro, NC 27401
City State Zip
Phone: office # 336-333-2872
[e-mail]
E-mail Address
408 South Elm Street
Current Street Address
Greensboro, NC 27401
City State Zip
Mobile # 336-2I5--6868
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current St r ddress
City State ip City State Zip
Phone: Office # Mobile #
ame 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:
Name of Registered Agent E-mail Address
Current Mailing Address Curre eet Address
City State Zip City State Zip
Phone: Offic 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.
Matt Brownell
Type or print name
Signature
Vice President
Title or Authority
6/6/2022
Date
--------------------------------------------
a Notary Public of the County of _
State of North Carolina, hereby certify that - 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 day of § , 20 r;,
�\ Notary
r
s c1 Seal �y
NOTARY = My commission expires
G PUBLIC 0:
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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:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Phone: Office # Mobile #
Name
Current Street Address
Current Mailing Address
City State Zip
City State
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Phone: Office # Mobile #
Name
Current Street Address
Current Mailing Address
City State Zip
City State
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Phone: Office # Mobile #
Name
Current Street Address
Current Mailing Address
City State Zip
City State
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 9 in Part B 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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #