NCC232351_FRO Submitted_20230810

6/2/23,7:48 AM Print Your Documents
LISPS CERTIFIED MAIL"'
Jessica Daley
LOVES
10601 N PENNSYLVAMA AVE
OKLAFIOMA CITY,OK 73120
9414 8149 0200 9208 3499 60
City of Winston Salem-Erosion Control
Matthew Osborne
PO Box 2511
Winston Salem,NC 27102
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((iij City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E. First Street,Suite 328,Winston-Salem,NC 27101
Wi1151011SO1l01 Mailing: PO Box 2511,Winston-Salem,NC 27102
Financial Responsibility/Ownership Form
No person may initiate any land-disturbing activity exceeding 20,000 square feet for Single-Family Dwelling construction, 10,000
square feet for any other non-exempt purpose,or part of a larger common plan of development exceeding these thresholds,before this
form and an acceptable Erosion Control Plan have been submitted,reviewed,and approved by the City of Winston-Salem Erosion
Control Division and a Grading/Erosion Control Permit has been issued. Please type or print.Please place"N/A"in the blank space if
not applicable.
Part A
Love's Travel Stop
Project Name:
Grading/Erosion Control Permit#: EN2300085
Location of Land-disturbing Activity: 2257 Shore Road,Rural Hall,NC 27045
Latitude:...36,2253.39 Longitude: -80.324158
Approximate Date that Land-disturbing Activity will Commence: June 19,2023
Purpose of Grading:
® Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑Other
Total Site Acreage: 22.34 acres Acreage to be Disturbed: 20.87 acres
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name. Tom Squires Email: ConstructionUtilities..,[e-mail]
Office Phone: [phone] Mobile Phone: [phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• 6910-03-0471 Tax Block#: 4968 Tax Lot#: 341
Name: Roserock Holdings,LLC
Street Address/PO Box: 10601 N.Pennsylvania Ave
City/State/Zip Code. Oklahoma City,OK 73120
Office Phone: ....4Q5-. Q2-6642 Mobile Phone: Fax#:
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract:$ City of WS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/PO Box:
City/State/Zip Code:

Part B
Person(s)or firms who are financially responsible for this land-disturbing activity: (use blank page to list additional
person(s)or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership***
Name of Person or Firm: Love's Travel Stops& Country Stores, Inc.
Street Address/PO Box: 10601 N. Pennsylvania Ave
City/State/Zip Code: Oklahoma City, OK 73120
Office Phone: [phone] Mobile Phone: Fax#:
If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent:
Name of Registered Agent. CT Corporation System
Street Address/PO Box• 160 Mine Lake Ct, Suite 200
City/State/Zip Code: Raleigh,NC 27615
Office Phone: [phone] Mobile Phone: Fax#:
If the financially responsible party is a partnership,provide information for each General Partner:
(use blank page to list additional partners if needed)
Name of Registered Agent:
Street Address/PO Box:
City/State/Zip Code:
Office Phone: Mobile Phone: Fax#:
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 their attorney-in-fact,or if not an individual,by an officer,
director,partner,or registered agent with 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.
Type or Print Name: Frank Love
Title or Authority: .. executive Officer
Signature: .. .. AO, — Date: .LI.12-1 202-3
1,.45SlC pak } ,a Notary Public of the County of... ?.V 9.
State of..!). It - 4 ,do hereby certify that flfA. .i4' , 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 ZXJPI day of-.lily- ,20 2-12
Notary Public Name: a f'? Y
s 2"°°46 s_
Notary Public Signature:(J _ �` A �° or
My commission expires: !" (�'2
Notary Seal

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