NCC215493_FRO Submitted_20211005

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 and/or fax
information unavailable, place N/A in the blank.)
Parrt A.
1. Project Name Dollar General - Wadesboro
2,
3.
4.
5.
Location of land -disturbing activity: County Anson
City or Township
Highway/Street 1179 US Hwy 74 Latitude 34.97795 Longitude-80.09121
Approximate date land -disturbing activity will commence: October 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.17 acres
6. Amount of fee enclosed: $ 130+500 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.010 (Example: 9 acres total is $2,585).
7
1
0
10
Has an erosion and sediment control plan been filed? Yes I No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Joe Strickland E-mail Address [e-mail]
Telephone [phone] Cell # Fax #>`
Landowner(s) of Record (attach accompanied page to list additional owners):
Pine Terrace Motor Co
Name Telephone
110 Marshville Water Plant Road 110 Marshville Water Plant Road
Current Mailing Address Current Street Address
Fax Number
Marshville NC 28103 Marshviile • NC 28103
City State Zip City State Zip
Deed Book No. 153 Page No. 493 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(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 or firm is a sole
proprietorship, the name of the owner or manager may be listed as the frnanciaily responsible party,
Teramore Construction, l_LC
Name
214 Klumac Road Suite 101
Current Mailing Address
[e-mail]
E-mail Address
Current Street Address
Salisbury NC 28144
City State Zip City State Zip

Telephone [phone] Fax dumber
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
City State Zip
Telephone
Current Street Address
city
Fax Number
State Zip
(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
(c) In 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:
BREC, PA
Engineering Firm or other consultant
Justin Church, PE
[e-mail]
E-mail Address
336-844-4088
Individual contact person (type or print) Telephone
336-609-7726
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 attomey-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.
Joe Si
Type or
Member
Title or Authority
Date' _... _... j
*A, & L 4- - 4 L ,,-1 24.AJ , a Notary Public of the County of
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State of North Carolina, hereby certify that `5 Ck S 71AXC T'L-f-A4 I appeared personally
before me this day and being duly sworn acknowledged that the above fo w s executed by him.
Witness my hand and notarial seat, this ] � day of '4 U 1 (j � � , 2p Z
DANIEL R ALNIAZM
N®T Rv PLEBLIC Natary
Se�wan County y p J UA! C
North Carolina M commission expires
/
L,my Commission Expires .Lune 25, 2022