NCC222226_FRO Submitted_20220706

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. Truby Drive Industrial
1. Proiect Name
2. Location of land -disturbing activity: CountyAlamance City or Township Graham
Highway/Street Truby Drive Latitude 36.073532 Longitude-79.354929
3. Approximate date land -disturbing activity will commence: 06/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 40.00
6. Amount of fee enclosed: $ 2,600 . 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:
Name Bob Brooks E-mail Address [e-mail]
Telephone cell # 919-816-6227 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Second Partners, LLC
[phone]
Name
Telephone Fax Number
2555 Saint James Dr SE Unit 403
2555 Saint James Dr SE Unit 403
Current Mailing Address
Current Street Address
Southport, NC 28461-8069
Southport, NC 28461-8069
City State Zip
City State Zip
10. Deed Book No. 4230 Page No. 0433 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.
Al Neyer LLC
[e-mail]
Name
E-mail Address
4509 Creedmoor Road, Suite 201
Current Mailing Address
Current Street Address
Raleigh, NC 27612
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:
ame
Current Mailing Addles
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
(.b) If the Financially Responsible Party is a Partnership pr 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:
Name of Registered Agent
Current Mailing Address
City
E-mail Address
Current Strut Address
State Zip City
TelephoneFax Number
State Zip
The above information is true and correct to the best of my knowledge and belief and was provided
by rite under oath (This form must be signed by the Financially Responsible Person if an individuall
or his attorney-ln-fac(, 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.
pa,� o-v�� —
-
Type or print name p
A'�}`f i
Sign tune
I Lt-s±_
Title or Authority
Date
-----------------------------------
1, ' a Notary Public of the County of 4<F_
State of North Carolina, hereby certify that P&bp5 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 1,4
Witness my hared and notarial seal, this ork'5. -_day of , 20
Notary
� ua� �ti�te�xe
My commIssion expires