NCC223683_FRO Submitted_20221028

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTIO
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 NameSOS I & II MANUFACTURING
2. Location of land -disturbing activity: County LEE City or TownshipSANFORD
3
4
COLON Ro. & BRICKYARD RD. 35.527521-79.158448
Highway/Street Latitude(decimaidegrees) Longitude(decimaidegrees)_
Approximate date land -disturbing activity will commence: June 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): INDUSTRIAL
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 36.36
6. Amount of fee enclosed $57700 . 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 m Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name 1"IA T( t>a&W E-mail Address A? Ayer
Phone: Office # TO- 2 g r- 27 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Daybreak Farms, LLC
Name
6131 Falls of Neuse Rd
Current Mailing Address
Raleigh NC 27609
City
State Zip
Phone: Office # Mobile #
6131 Falls of Neuse Rd
Current Street Address
Raleigh NC 27609
City
State
Zip
10. Deed Book No. 1664 Page No. 883 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), the n me(s) of the owner(s) may be listed as the financially responsible party(ies).
�r' ro inS/ ��a7,o��crvky �"fnGl�J fi'r/Jrar�
Companj Name E-mail Address
S42S ?-Ae (� . �k lyv
Current Malling Address
00 JUK IV 2T7o�
City State Zip
Phone: Office #
ry2"­ PG &( , -5-fx lab
Current Street Address
s
00.1h,01111 fijC Z 77 -s
City State Zip
Mobile # 115 ' 2d(— S3 ZS
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, ive name and street address of the Registered Agent:
Name of egi tered Agent
100
�y 5 9eXLit 9_04d _.
Current Mailing Address
v(�Csr% N L 277 03
City State Zip
Phone: Office # I i q 2 �1
E-mail Address
`5 A IS Pug c goo c)
Current Street Address
�,k4i�n Yy
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:
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
(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 preparation:
The Site Group
Engineering firm or other consultant
Samuel R. Nye, PE
SRN@thesitegroup. net
E-mail Address
919-835-4787 919-996-9136
Individual contact person (type or print) 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 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.
N4 W/k -J a
Type or print name
/�4&
Signature
AV'r (-
Title or Authority
612f12Z
Date
I�"i1G' , a Notary Public of the County of C
State of North Carolina, hereby certify that I' VVhtw M. 94V-t r appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness m hand and notarial seal, this Ada of 20
Y Y C4 -
SHANETHA LANGLEY t
NOTARY PUBLIC s-
Wake County ry
N h 1-
m