HomeMy WebLinkAboutNCC230181_FRO Submitted_20230123FINANCIAL~ RESPONSIBILITYIOWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
Project Name Royal Farms — Store #523
2. Location of land -disturbing activity: County Bertie City orTownship Windsor
Highway/Street US-13 Byp & Sterlingworth St. Latltude(decimal degrees) 36.003778 Longitude(decimal degrees) 76.961694
3. Approximate date land -disturbing activity will commence: February, 1 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.15
6. Amount of fee enclosed: $ 400.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee
is $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 Dan Withers, PE E-mail Address Dan.Withers ArkConsultin Grou .com
Phone: Office # 252-565-1017 Mobile #
Landowner(s) of Record (attach accompanied page to list additional owners):
01 McDonalds USA LLC & (2) Tillman Windsor LLC
Name
One McDonald's Plaza
Current Mailing Address
Phone: Office It Mobile #
1004 Wake Forest Rd
Current Street Address
Oak Brook IL 60523 Raleigh NO 27604
City State Zip City State Zip
10. Deed Book No. 958 & 945 Page No. 893 & 261 Provide a copy of the most current deed.
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 company is 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).
Two Farms, Inc
Company Name
3611 Roland Ave.
Current Mailing Address
Baltimore MID 21211
City State Zip
_realestate@royalfarms.com
E-mail Address
Current Street Address
City
Phone: Office # (410) 484-7010 Mobile #
State
Zip
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:
Registered Agent Solutions, Inc,
Name of Registered Agent
176 Mine Lake Court Ste. 100
Current Mailing Address
Raleigh NC_ 27615
City State Zip
E-mail Address
Current Street Address
City
Phone: Office # 888-705-7274 Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of individual to Contact (if Registered Agent is a company)
(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 DBA Name
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.
Joshua Wolfe
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Title or Authority
1016 z 'z�
Date
a Notary Public of the County of C-4v&-011
State of M Avy 1 and , hereby certify that G W O l �e— 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 6+h day of December , 20-:) .2,
Notary "
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