NCC222861_FRO Submitted_20220810

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Albemarle Kings Mountain
2. Location of land -disturbing activity: County Cleveland City or Township Kings Mountain
Highway/Street
Holiday Inn Dr Latltude(decimal degree35.216726-81.353115
s) Longltude(decimal degrees)
3. Approximate date land -disturbing activity will commence:August 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Mining
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.68 acres
6. Amount of fee enclosed $2 5 1 gg . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). 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 John Kuhn E-mail [e-mail]
Phone: Office # NSA Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached table
Name Phone: Office # Mobile #
Current Mailing Address
City
Current Street Address
State Zip City
State
Zip
10. Deed Book No. Page No. 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 or if the landowner(s) is
an individual(s), Me name(s) of the owner(s) may be listed as the financially responsible party(ies).
Albemarle U.S., Inc.
Company Name
4250 Congress St. Suite 900
Current Mailing Address
Charlotte NC 28209
City
State Zip
[e-mail]
E-mail Address
4250 Congress St. Suite 900
Current Street Address
Charlotte NC 28209
City
State
Phone: office # 980.299.5700 Mobile # [phone]
Zip
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
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
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:
CT Corporation System
Name of Registered Agent
160 Mine Lake Ct. Suite 200
Current Mailing Address
Raleigh NC 27615
city State Zip
[e-mail]
E-mail Address
160 Mine Lake Ct. Suite 200
Current Street Address
Raleigh NC 27615
City
Phone: office # 919.844.8360 Mobile #
Karen Rozar
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.
Company DBA Name
(d) If order to facilitate Express Permitting, It is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary Information regarding the plan and its preparatlon:
SWCA
Engineering firm or other consultant
Joshua Allen
Individual contact person (type or print)
[e-mail]
E-mail Address
980.305.5750 919.624.1458
Phone: Office # Mobile #
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 attomey-in-fact, or K 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.
Donald J. LaBauve, Jr. Vice President/Chief Financial Officer
Type or print name
�Tv _W_44�
Signtatbre
Title or Authority
g"' , Zo ZZ
Dat9_
tary Public of the County of
State of North Carolina, hereby certify that bMktZT LA4V r� i Q (— appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Ir
Witness my hand and notarial seal, this ayjNo
r 20 2-�
ry
' z -
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My commission expires 3 Z J ZD 26

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:
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 4 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 5 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.

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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
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 #

PIN
Parcel Address
Area (acres)
Deed Book/Page
Owner
Owner Address
2594961439
801 S Battleground Ave
55.718
1806/2603
ALBEMARLE U S INC
2594854118
S Battleground Ave
1.742
1806/2603
ALBEMARLE U S INC
2594543069
114 Raven Cir
55.07
1860/2798
ALBEMARLE U S INC
2594612532
348 Holiday Inn Dr
536.043
1858/1265
ALBEMARLE U S INC
2594301281
Dixon School Rd
57.633
1863/314
ALBEMARLE U S INC
2593378933
152 Tin Mine Rd
29.61
1806/2603
ALBEMARLE U S INC
3504015053
Holiday Inn Dr
33.36
1806/2603
ALBEMARLE U S INC
135033802461
Lake Montonia
1 470.871
1783/0539
JALBEMARLE U S INC