NCC215526_FRO Submitted_20211006

DocuSign Envelope ID: 99E76OE5-76E6-47D5-9BEF-180492665539
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 and/or fax
information unavailable, place NIA in the blank.)
Part A.
1. Project Name Dollar General - Ennice
2. Location of land -disturbing activity: County Aileghany City or Township Ennice
Highway/Street Hwy 18 N Latitude 36.560220 81.943113
longitude'
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 1.79 acres
6. Amount of fee enclosed: $ 130+500 = 630 The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next 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 $2,585).
T. 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 Joe Strickland E-mail Address [e-mail]
Telephone [phone] Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Dennis & Linda Glasco
Name Telephone Fax Number
3957 NC Hwy 18 South 3957 NC Hwy 18 South
Current Mailing Address Current Street Address
Moravian Falls NC 28654 Moravian Falls NC 28654
City State Zip City State Zip
10. Deed Book No. 216 Page No. 885 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.
Teramore Construction, LLC jtrickland@teramore, net
Name E-mail Address
214 Klumac Road Suite 101
Current Mailing Address Current Street Address
Salisbury NC 28144
City State Zip City State Zip

OocuSign Envelope ID: 99E760E5-76E6-4705-9BEF-180492665539
Telephone [phone] Fax Number
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:
Name
Current Mailing Address
City
State Zip
E-mail Address
Lurrent Street Address
City
Telephone Fax Number
State zip
(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
t-mail Address
Current Street Address
City State Zip
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:
BREC, PA
Engineering Firm or other consultant
Justin Church, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
336-844-4088 336-609-7726
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.
Joe Si
Type or
Member
Title or Authority
Date „_.. .....�..
I, L,M474,1 , a Notary Public of the County of A 0 w�N
State of North Carolina, hereby certify that 3 ° r ST /ZZ-614 L-f-ivQ appeared personally
before me this day and being duly swom acknoMedged that the above form vv executed by him,
Witness my hand and notarial seal, this day of SZ1r',C1Y13r/L 20 Z 1
DANIEL RALMAZAN-`���-
WanY PUBLIC Notary
County
North Carolina My commission expires 0 VA/ G 2 5 2, 0 1'L
My Commission Expires June 25, 2022