NCC230336_FRO Submitted_20230207

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 NameCAI Inc Rockingham Site Preparation
h` this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding lhuouyir tie Divis;an OrWater If trasdruc ure ; DWl).
2. Location of land -disturbing activity: CountyRichmond City or Township Rockingham
Highway/Street
106 Enterprise Drive LatltUde{decimal degrees) 34.9637-79.8042
�r} Longitude{de��mai degrees}
3. Approximate date land -disturbing activity will commence: i 0/1 5/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.473
6. Amount of fee enclosed: $2, 780.00 . 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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kin Chaco, Maintenance Manager
Phone: Office # 91 0.895.5779
E-mail Addressjchaco.caiink.com
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rockingham Group, LLC. 978-352-4510 978-352-4519
Name
106 Enterprise Drive
Phone: Office # Mobile #
106 Enterprise Drive
Current Mailing Address Current Street Address
Rockingham, NC 28379 Rockingham, NC 28379
City State Zip City State Zip
10. Deed Book No. 1 558 Page No.399 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 names) of the owner(s) may be listed as the financially responsible party(ies).
CAI, Inc.
Company Name
7 Martel Way
Current Mailing Address
Georgetown, MA 01833
City State
Phone: office # 978-352-4510
[e-mail]
E-mail Address
7 Martel Way
Current Street Address
Georgetown, MA 01833
Zip City
Mobile #
State
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:
Rockingham Group, LLC
Name of Registered Agent
106 Enterprise Drive
Current Mailing Address
Rockingham, NC 28379
city
[e-mail]
E-mail Address
106 Enterprise Drive
Current Street Address
Rockingham, NC 28379
state Zip City
Phone: office # 978-352-4510 Mobile #
Paul Sartorelli
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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: office # Mobile #
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
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). 1 agree to provide
corrected information should there be any change in the information provided herein.
Robert A. Ficke
Director of Regulatory Compliance
Title or Authority
1 /24/23
Date
1, ''iscilta L. Kindler , a Notary Public of the County of $ichmor-,d
State of North Carolina, hereby certify that Rob-, r+ A.:6- Cb appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this Z4 day of %Tdnuu&nr .2013
C. k
J?Wctya L. Kind
otary
4QTARY -�
i —* - i - My commission expires
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