NCC222396_FRO Submitted_20220706

JOHNSTON COUNTY 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
Johnston County Department of Public Utilities. (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.
1. Project Name Dunkin' Donuts - Flowers Plantation
2. Location of land -disturbing activity: City or Township Clayton
Highway/Street NC Hwy 42 Latitude 35.6486' N
3. Approximate date land -disturbing activity will commence: 1211121
Longitude-78.3924* W
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.9
6. Amount of fee enclosed: $ 330.00 . The application fee of $330.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $110 per acre for each
additional acre (rounded up to the next acre).
7
7
Has an erosion and sediment control plan been filed? Yes No Enclosed T
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Curtis Little E-mail Address [e-mail]
Telephone [phone] Cell # 843-906-0882 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Clayton 99, LLC 919-719-5425
Name Telephone
4321 Lassiter at North Hills Ave, Suite 250 Same as mailing address
Current Mailing Address
Raleigh NC 27609
City
10. Deed Book No.
5547
State
Current Street Address
Fax Number
Zip City State Zip
Page No. 273
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):
MOC Flowers, LLC [e-mail]
Name E-mail Address
500 6th Street
Current Mailing Address
San Antonio TX
City State
Telephone [phone]
Current Street Address
78215
Zip City State
Fax Number
Zip

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:
Northwest Registered Agent Service, Inc. [e-mail]
Name
4040 Wake Forest Road, Suite 349
Current Mailing Address
Raleigh
NC 27609
City State Zip
Telephone [phone]
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:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
Curtis Little - Mount Oak Capital Managing Partner
Type or print name
f i
Si ature
Title or Authority
Date
I0I26 12-1
�G 1 a Notary Public of the County of C 1­'q �Ir5�u�1
State of Neff Carolina, hereby certify that 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, thik day of 20-_
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