NCC230692_FRO Submitted_20230315

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 Environment and Natural Resources. (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.
1. Project Name Gold Bond Building Products Rock Unloading Project
2. Location of land -disturbing activity: County hanover City or Township vvnmington
Highway/Street 838 Sunnyvale Drive Latitude 34.1734 Longitude-77.9467
3. Approximate date land -disturbing activity will commence: 03/20/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.64
6. Amount of fee enclosed: $ 780 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tim Chesley E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gold Bond Building Products, LLC 704-365-7300
Name Telephone
2001 Rexford Road
Current Mailing Address Current Street Address
Charlotte NC 28211
Fax Number
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
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):
Gold Bond Building Products, LLC [e-mail]
Name E-mail Address
2001 Rexford Road
Current Mailing Address Current Street Address
Charlotte NC 28211
City State Zip City
Telephone [phone] Fax Number.
State
Zip

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.
Todd Broud
President
Type
or print name Title or Authority
4t4j/,9_Z-j3 l `1 207- 3
Signature Date
a Notary Public of the County ofL-ffk�JkLAYOJ
Y�State of North Carolina, hereby certify that i) _appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and not 61gju%%q this day of __ (YLL, 20 23 AC
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Seal PUBLIC
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