NCC222999_FRO Submitted_20220824

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name_ Lawndale Retail Store
2. Location of land -disturbing activity' County Cleveland City or Township Lawntfale
Highway/Street 226 E. Stage Coach Trail (State Hiwav 182) Latitude 35.4180 Longitude-81,5349
3. Approximate date land -disturbing activity will commence: Sept 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.80 Acres
6. Amount of fee enclosed 200 + $500 = $70o. The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert M. Broadway
Phone: Office # (256).533-7287
E-mail Address carson, sty [e-mail]
Mobile # (256)_ 679-1913
9 Landowner(s) of Record (attach accompanied page to list additional owners): (See attached)
RTJ, LLC
Name
A NA
Phone: Office # Mobile #
1015 W. Sta a Coach Trail
Current Mailing Address Current Street Address
Lawn.dale NC 28090 _
City State Zip City State
10. Deed Book No. 1332 Page No. 1287 Provide a copy of the most current deed.
W&

Part B.
1 Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
The Broadway Group of Alabama LLC carson.s les ct7i broadwa rou .net
Company Name E-mail Address
216 Westside Square 216 Westside S uare
Current Mailing Address Current Street Address
Huntsville AL 35801 Huntsville AL 35801
City - - - - Stag - Zip City - -State - Zip
Phone: Office # [phone] _ Mobile # L256)_679-1913
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
NLA N//A
Name of Registered Agent E-mail Address
IN1A V/A
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office #
Mobile #
NA
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
S10 �a5 PeAy soon _
Name o Registered Agent
-(III N 5+. S4,_ j o lt
Current Mailing Address
R7 AAir f 121A ^ t. w"
E-mail Add ss
r— 7 a.w. G
Current Street Address
�cv►d,trc ev.uillr� � C.���19 2 � �— S�M...4 —
City State Zip City
Phone: Office # (E Z T) 4 Zj - q S 59 Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company ❑BA Name
(d) If 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:
Civil Desi n Concepts. PA
Engineering firm or other consultant
Jesse Gardner _
Individual contact person (type or print)
[e-mail]
E-mail Address
[phone] [phone]
Phone: Office # Mobile #
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Robert M. Broadway
Typ
Signature
--------------
President Managing Member
Title or Authority
-7/II/ZZ
Date
a Notary Public of the County of Mad.soin
AIab0.�.
State of hereby certify that &6crt M Rvoad....,,j _ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 1L�_day of l 20 2 2
Notary
My commission expires
My COMMISSION EXPIRES 6-8-2026

Continued from items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
RTJ: 1 1
NA NA
Name
Phone: Office # Mobile #
1015 W. Sta a Coach Trail
Current Mailing Address
Current Street Address
Lawndale NC 28090
City state ZIP
City State Zip
Deed Book No. 1332 Page No. 1287
Provide a copy of the most current deed.
Landowner 3 of Record
RTJ, LLC
NA NA
Name
_
Phone: Office # Mobile #
1015 W. Stage Coach Trail
Current Mailing Address
_
Current Street Address
Lawndale NC 28090
City State Zip
City State Zip
Deed Book No. 1430 Page No. 1542
Provide a copy of the most current deed.
Landowner 4 of Record
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Deed Book No. Page No.
Provide a copy of the most current deed
Landowner 5 of Record:
Name
Current Mailing Address
City State
Deed Book No -
Phone: Office #
Current Street Address
Zip City
Page No._
Mobile #
State Zip
Provide a copy of the most current deed_