NCC220720_FRO Submitted_20220210

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
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 N/A in the blank.)
Part A.
FA
3.
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5.
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7.
8.
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Project Name Sanford St Andrews Church Road Dollar General
Location of land -disturbing activity: County Lee City or Township Sanford
Highway/Street NC 705 Latitude 35.434597 Longitude = 79.165747
Approximate date land -disturbing activity will commence: February 15, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.8 ac
Amount of fee enclosed: $ 200.00 . The application fee of $100.00 per acre (rounded up
to the next acre) is assessed without a ceiling amount (Example: a 8.10-acre application fee is $900).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Parker E-mail Address iohn(cDrhetson.com
Telephone [phone] Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
BGS Winstead Partners
Name
1324 Asbury Church Road
Current Mailing Address
Sanford NC 27330
City State Zip
Telephone Fax Number
Current Street Address
City State Zip
10. Deed Book No. 1404 Page No. 786 Provide a copy of the most current deed.
Part B.
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.
Rhetson Companies, Inc iamie _rhetson.com
Name E-mail Address
2075 Juniper Lake Road
Current Mailing Address Current Street Address
West End NC 27376
City State Zip City State Zip

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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 infor tion provided therein.
Type or prir Title or Authority
CGS 500 �
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him.
Witness my hand and notarial seal, this
CASSIE SCOTT
NOTARY PUBLIC
Moore County
N roAns
Connnlasiof ires A ust 29, 2023
— i i ln-b u,,
Date
a Notary Public of th County of N �00v-�
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appeared
duly sworn acknowledged that the above form was
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day of I G/e '-y'�Xti/ , 20 DI
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Notary
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