NCC230260_FRO Submitted_20230130

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name TBMNC BEV Phase 1
2. Location of land -disturbing activity: CountyRandolph City or TownshipLlberty
5938 Julian Airport Rd. N35.891497 w79.635018
Highway/Street LatltUde(decima�degreesy LOngltUde(decimaldegrees�
3. Approximate date land -disturbing activity will commence:OCtober 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 325 acres
6. Amount of fee enclosed: $ 32,500 . 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 ❑ Enclosed ❑x No ❑
r:3
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameRebecca Bright E-mail [e-mail]
Phone: Office # 502-642-1642 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Toyota Battery Manufacturing, Inc. 502-867-2299
Name Phone: Office # Mobile #
6565 Headquarters Dr., W14D
Current Mailing Address
Plano TX 75024
Current Street Address
City Q State Zip City
10. Deed Book No.281 0 Page No.1683-1719
State
Zip
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 name(s) of the owner(s) may be listed as the financially responsible party(ies).
Toyota Battery Manufacturing, Inc.
Company Name
151 Engineering Way
Current Mailing Address
Georgetown, KY 40324
[e-mail]
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office # 502-867-2299 Mobile #
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
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Street Address
City
State Zip
Phone: Office # 866-665-5799 Mobile # [phone]
Lance Farris
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 -tact, 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.
April Mason General Manager, Plant Services
or prjpt name Title or Authority
8/23/22
Date
I, �/-N' \- --e_` _, a Notary Public of the County of fy� 941. 110_
1q 1ob�r+. a
State of NeftZaa4oa, hereby certify that ('N osDkn _appeared personally
before me this day and being duly sworn acknowle ed that the above form was executed by him/her.
Witness my hand and notarial seal, this )3 day of W u , 20 31)
Nota
My commission expires 8 - 1 - a.3