NCC240024_FRO Submitted_20240119

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
l.R E D L.L L No person may initiate any land-disturbing activity on one or more acres, 1/2 acre or more inside a
COUNTY NC watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning&Development, Erosion Control Section.
(Please type or print.)
Part A.
1. Project Name NCP4077 Phase 1 Offsite Roadway Improvements
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Odessa Drive/
Highway/Street Crawford Road Latitude35.83 degrees mLongitude80.86 degrees W
3. Approximate date land-disturbing activity will commence: November 2023
4. Purpose of development(residential, commercial, industrial, institutional,etc.): Industrial (NCDOT Improvements)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10 aC
6. Amount of fee enclosed: $1750 . An application fee of$175.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount (Example: a 9-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed,a flat fee of$135.00 is assessed.
7 Has an erosion and sediment control plan been filed? Yes_ No Enclosed X
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dustin Camloh E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9 Landowner(s)of Record(attach accompanied page to list additional owners):
NP BGO NC Park Statesville, LLC
Name Telephone Fax Number
3315 N Oak Trafficway
Current Mailing Address Current Street Address
Kansas City, MO 64116
City State Zip City State Zip
10. Deed Book No. 2920 Page No 446 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):
NP BGO NC Park Statesville, LLC Dustin Camloh, [e-mail]
Name E-mail Address
3315 N Oak Trafficway 3700 Arco Corporate Drive, Suite 425
Current Mailing Address Current Street Address
Kansas City, MO 64116 Charlotte, NC 28273
City State Zip City State Zip
Telephone [phone] Fax Number
Page 1 of 2

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:
Karen Rozar do CT Corporation System [e-mail]
Name E-mail Address
160 Mine Lake CT,Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] 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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake CT.Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] 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 by any change in the information provided herein.
Nathaniel Hagedorn Manager of NPD Management,LLC,the Manager of NP BGO NC Park
Statesville JV,LLC,the Sole Member of NP BGO NC Park Statesville,LLC
Type or print name Title or Authority
303
Sig re ate
I. 1--_.t Ski, s a Notary Public of the County of r t(a
State of Missouri, hereby certif hat Nathaniel Hagedorn appeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this 2 day of tatSl. ,20 a"3
—44e44-
Seal N —10—d-3
My commission expires
LISA L BEASLEY
AC41 in C,ta, C,atA r►-h.
Notary Public-Notary Seal
Platte County-State of Missouri
Commission Number 19497557
My Commission Expires Sep 10, 2023
Page 2 of 2