NCC233637_FRO Submitted_20231220

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 and!
or fax information unavailable,place N/A in the blank.)
Part A. Pfizer Sanford North
1. Project Name-
2. ` Location of land-disturbing.activity: CountyLee City or TownshipSanford
Highway/Street 75 Enterprise.Park Dr Latitude35.5609 Longitude`79.1577
3, Approximate date land-disturbing activity will commence:August 2021
4. Purpose of development(residential,commercial,industrial,institut'ionai,etc.):tndustriai
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 13-'S ,
6. Amount of fee enclosed:$ NIA . The application fee of$100.00 per acre o i,aa/` 3
(rounded up to the next acre)is assessed without a ceiling amount(Example:B.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Elias Galloway E mail Address Elias.Galloway ct�pfizer.com
Telephone [phone] Cell#910-622-3046 Fax# N/A
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Pfizer (North Carolina) LLC 919-566-4310 N/A
Name Telephone Fax Number
6075 Enterprise Park.Dr 6075 Enterprise Park Dr
Current Mailing Address Current Street Address
Sanford, NC 27330 Sanford, NC 27330
City State Zip City State zip
10.. Deed Boole No.1640 Page No.846 Provide a copy of the most:current deed.
Part B.
1. Cornpany(les) or fimi(s) Who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company orfrm Is a sole proprietorshipp,
the name of the owneror manager may be listed es the financially responsible party.
Pfizer(North Carolina) LLC Jon.Tucker©pfizer.corn
Name E-mail Address
6075 Enterprise Park Dr 6075 Enterprise Park Dr
Current Mailing Address Current Street Address
Sanford, NC 27330 Sanford, NC 27330
City State Zip City State zp
Telephone9'19-566-4310 Fax Nurnberg/A

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:
N/A
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:
N/A
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.
Jon Tucker Site Leader- Sanford
Type or print name Title or Authority
1f
Signature Date
!, W ei 1.,. L,A t icrEa-h , a Notary Public of the County of Lee
State of North Carolina, hereby certify that - :-s4t?t`tc • appeared.
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
ik
Witness my hand and notarial seal,this 3 } day of
l 5o a'
j61 k ems.
NEll tAIRTf?0 Notary
Nota tbltc-North Carolina.
`'e County My commission expires !is "1 dzi
My commission Expires Jul 10,2024 r