NCC215528_FRO Submitted_20211006

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 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 NIA in the blank.)
Part A. AutoZone Murphy NC
1. Project Name p y
2. Location of land -disturbing activity: County Cherokee City or Township Murphy
Highway/street 226 Bulldog Dr Latitude 35.09842 N Longitude 84.01667 W
3. Approximate date land -disturbing activity will commence: 10/1 /21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): New AZ Retail Store
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.24
6. Amount of fee enclosed: $ 130.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJay LUStIg E-mail Address lay'wrightld.com
Telephone [phone] cell # same Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Vinpetro, LLC
Name Telephone Fax Number
7555 Blue Ridge Dr
Current Mailing Address Current Street Address
Blue Ridge, GA 30513
City State Zip City State Zip
10. Deed Book No. 1414 Page No. 400 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 financially responsible party.
AZ Murphy LLC [e-mail]
Name E-mail Address
2400 Old Brick Rd, Suite 119 same
Current Mailing Address Current Street Address
Glen Allen VA 23060
city
State Zip City
State
Telephone [phone] Fax Number N/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:
see below for Registered Agent
Name
Current Mailing Address
City
Telephone.
State Zip
E-mail Address
Current Street Address
City State Zip
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:
Northwest Registered Agent Service, Inc.
Name of Registered Agent E-mail Address
4030 Wake Forest Rd, Suite 349
Current Mailing Address
Raleigh, NC 27609
City
Telephone
Current Street Address
State Zip City
Fax Number
State Zip
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.
CAR L_ ujl-16 t-
Type or print name
Signature
A�Met�K
Title or Authority
<31+-11
Date
I, MvlP5A- fL • ?r?-I Cl a Notary Public of the County of �L-MkA Yt
I�GtA+�iS�t�w �
State of a, hereby certify that CAVL WI-lfiH-T- 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 1-1
Commonwealth of Pennsylvania — Notary Seal
MARISA E PRICE — Notary Public
Delaware County
My Commission Expires Apr B. 2022
5 tal Comrission Number 1282835
day of T1 v 20 Z r
Notary
My commission expires In l , UZZ-