NCC230544_FRO Submitted_20230228

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 NIA in the blank.)
Part A.
1. Project Name GERRESHEIMER GLASS WAREHOUSE
2. Location of land -disturbing activity: County BURKE City or Township MORGANTON
114 wAMSLITTA MILL ROAD ss.748-81.710
Highway/Street Latitude(dodmaldegrees) Long itudeideumaidegrees)
3. Approximate date land -disturbing activity will commence: 2120123
4. Purpose of development (residential, commercial, industrial, institutional, etc.): IND WARERHOUSE
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.40
B. Amount of fee enclosed 600 `E 1500 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 21 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameKEViN BROOKSHIRE
Phone: Office # 828-754-6431
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BRIGAM PROPERTIES LLC 828-390-5040 828-390-5040
Name Phone: Office # Mobile #
PO BOX 2508
Current Mailing Address
MORGATNON NC 28680
City
600 EAST UNION ST
Current Street Address
MORGANTON NC 28680
State zip City
State
Zip
10. Deed Book No. 2544 Page No. 827 Provide a copy of the most current deed.

Part S.
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 names) of the owner(s) may be listed as the financially responsible perty(ies).
GERRESHEIMER GLASS INC.
Company Name
537 CRYSTAL AVE
Current Mailing Address
VINELAND, NJ 08360
City State Zip
Phone: office # 856-896-6260
[e-mail]
E-mail Address
SAME
Current Street Address
City State Zip
Mobile # [phone]
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 [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Suite 200 160 Mine Lake Ct, Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27615-6417
City State Zip
Rasleigh, NC 27615-6417
City
Phone: Office # 919-84408360 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 preparation:
CLAYTON ENGINEERING
Engineering firm or other consultant
WILLIAM CLAYTON
Individual contact person (type or print)
[e-mail]
E-mail Address
828-455-3456 828-455-3456
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.
Craig Calloway
Type or print name
Signatyre -
VP Human Resources
Title or Authority
2/15/23
Date
I, �'a v, tlA'� � 3 -7-a-Notary Public of the County of VVW4_
State of North Carolina, hereby certify that(It A a 1� a� A appeared personally
before me this day and being duly sworn acknowled6ed that the abov form was executed by him/her.
Witness my hand and notarial seal, this 7:4Lday of Tewr-kj, 20Q13
,•`�p�N F: HA�q''% Notary -
il,06OTAgy ' : Z + My commission expires 1 -2 b
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