NCC224153_FRO Submitted_20221220

JOHNSTON COUNTY 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
Johnston County Department of Public Utilities. (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.
Project Name TCG Warehouse Expansion
Location of land -disturbing activity: City or Township Cleveland
Highway/Street Technology Dr Latitude35.611559 Longitude78.568176
Approximate date land -disturbing activity will commence:
May 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
, O AC
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas).
6. Amount of fee enclosed: $mod 1343 0 The application fee of $330.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $110 per acre for each
additional acre (rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jim Bell E-mail Address [e-mail]
Telephone [phone]- Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AIS Properties, LLC 919-779-8649
Name Telephone Fax Number
319 Chapanoke Rd, STE 102 319 Chapanoke Rd, STE 102
Current Mailing Address Current Street Address
Raleigh, NC 27603-3433 Raleigh, NC 27603-3433
City State Zip City State Zip
10. Deed Book No. 05901 Page No. 0906
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
AIS Properties, LLC [e-mail]
Name E-mail Address
319 Chapanoke Rd, STE 102 319 Chapanoke Rd, STE 102
Current Mailing Address Current Street Address
Raleigh, NC 27603-3433 Raleigh, NC 27603-3433
City State Zip City State Zip
919-779-8649
Telephone 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 Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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 individual
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
0 4heAA erks ftw1r
Type or print a e Title or Authority
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Signature Date
I, XL ,i uj6A- ,!`C7U_ , a Notary Public of the County of
State of North Carolina, hereby certify that X�(_(�LiL�`—��LC fa I1,CiLJi appeared
personally before me this day and being d lu y sworn ackno ledged that the above form was
executed by him.
Witness myJighdian4 notarial seal,
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this `(day of - Ali_ , 20
Notary
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