NCC222477_FRO Submitted_20220711

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name OVG 11 Truck Parking 11
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
(decimal degrees)
Highway/Street
Forsythe Street Latitude g ) 35.041106 Longltude(decimai degrees) 78 917731
3. Approximate date land -disturbing activity will commence: June 20, 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 .3
6. Amount of fee enclosed: $ 200 . 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 p No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
2
NameJared Fryer
Phone: Office # 910-483-7666
E-mail [e-mail]
Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Shoppes at Village Green, LLC 910-483-7666
Name
505 Forsythe Street
Current Mailing Address
Fayetteville NC 28304
City State
910-309-4334
Phone: Office # Mobile #
Current Street Address
Zip City
10. Deed Book No. 7842 Page No. 527
State
Zip
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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Shoppes at Village Green
Company Name
505 Forsythe Street
Current Mailing Address
Fayetteville NC 28304
City State
Phone: Office # 910-483-7666
[e-mail]
E-mail Address
Current Street Address
Zip City State
Mobile # [phone]
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:
Jared Fryer
Name of Registered Agent
505 Forsythe St
Current Mailing Address
Fayetteville NC 28304
City
State
Phone: Office # 9104837666
[e-mail]
E-mail Address
Current Street Address
Zip City
Mobile # [phone]
State Zip
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:
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.
Jared Fryer
Type or print name
Sign
Manager
Title or Authority
5/24/22
Date
r�. �/ �J,.,
1, _ Anclro k . 1.� ((1 , a Notary Public of the County of ,hhedQncL
State of North Carolina, hereby certify that JNed az er appeared personally
before me this day and being duly sworn acknowledged t the above form was executed by him/her.
Witness my hand and notarial seal, this 'iyday of 201 _
S A N D R A K C A I N
Notary Public, North Carolina Notary
Cumberland County
My Commission Expires
October 25, 2023 My commission expires (�

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:
Dark Branch Properties II, LLC
910-483-7666 910-309-4334
Name
Phone: Office # Mobile #
505 Forsythe Street
Current Mailing Address
Current Street Address
Fayetteville NC
28304
City State
Zip
City State Zip
Deed Book No. 7842
Page No. 531 Provide a copy of the most current deed.
Landowner 3 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 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
State Zip
Provide a copy of the most current deed.
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.