NCC220909_FRO Submitted_20220302

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. LibertyTire & Recycling Facility CCEP Lot #14
1. Project Name y g y -
2. Location of land -disturbing activity: County Lee City or TownshipSanford
Highway/Street Womack Rd. Latitude 35.557270 Longitude -79.176973
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.78 Ac.
6. Amount of fee enclosed: $ 2,450.00 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per 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 $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
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 Tony Bornhorst
E-mail AddresstonyC rhetson.com
Telephone [phone]
cell # 910-585-3896 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
5400 Womack, LLC
910-994-0881 N/A
Name
Telephone Fax Number
2075 Juniper Lake Rd
2075 Juniper Lake Rd
Current Mailing Address
Current Street Address
West End, NC 27376
West End, NC 27376
City State
Zip City State Zip
10. Deed Book No. 01615
Page No. 0991 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.
Rhetson Companies, Inc. [e-mail]
Name
E-mail Address
2075 Juniper Lake Rd
2075 Juniper Lake Rd
Current Mailing Address
Current Street Address
West End, NC 27376
West End, NC 27376
City State
Zip City State Zip
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:
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
(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:
CE Group, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Jacob C. Hudson, PE 919-367-8790 x. 110 N/A
Individual contact person (type or print) 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.
Brian Clodfelter chl_4
Type or pr' nam Title or Authority
Z- q- 2o22
Signature Date
I, Jenni;,ev- IWmckl h4ep- , a Notary Public of the County of t6 opz
State of North Carolina, hereby certify that C3Rio_n Clod -Pelf 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 Ot}h day of ebeLAO-e.20 22
ENNIMRgWI Pua GOFER otary
ilhe county
North Carolina My commission expires 2.1 2.d2C0
1_yCornn*Won F�gnw April 21. 202d

February 9, 2022
DEMLR — Erosion Control
3800 Barrett Drive
Raleigh, NC 27609
Attn: Permitting
Re: Liberty Tire & Recycling (CCEP Lot 14) Womack Rd, Sanford, NC
As landowner of parcel identified by Lee County GIS Pin# 9645-77-5741 located along Womack Road
Sanford, NC please allow this letter to serve as consent and agreement in granting Rhetson
Companies, Inc. permission to Permit and Construct per plans entitled "Liberty Tire & Recycling (CCEP
Lot 14)" prepared by the CE Group, Inc. Should you have any additional question or require additional
information please feel free to contact me at [phone].
Sincerely,
Brian R. Clodfelter, President
5400 Womack, LLC
a Notary Public for the State of North Carolina,
County of I AQQ e , do hereby certify that Brian R. Clodfelter, President 5400
Womack, LLC, personally appeared before me this ��day of FEbQUQk'q , 2022, and
being duly sworn acknowledged that the above signature was executed by him in the capacity
indicated.
Witness my hand and notarial seal, this day of tZldQ1Z , 2022.
Notary
My commission expires 2l a CP
JENNIFER WINCKLHOFER
NOTARY PUBLIC
Moore County
North Carolina
My Commission 00res Aprff 21. 2028