HomeMy WebLinkAboutNCC222495_FRO Submitted_20220722FINANCIAL 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 Environment and Natural Resources. (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.
1. Project Name Dollar General
2. Location of land -disturbing activity: County Brunswick City or Township Su
Highway/Street Boones Neck Rd Latitude 33, 55, 50N Longitude 78, 19, 27W
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.5
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: a 9-acre application fee is $900).
7. 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 John Parker— Rhetson Companies, Inc. E-mail Address john�rhetson.com
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mitchem Mark Worthv
Name Telephone Fax Number
302 South Clear Creek
Current Mailing Address Current Street Address
Friendswood TX 77546
City State Zip City State Zip
10. Deed Book No. RE 290 Page No 559 Provide a copy of the most current deed. *Attached
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Rhetson Companies. Inc.
Name E-mail Address
2075 Juni er Lake Dr.
Current Mailing Address Current Street Address
West End NC 27376
City State Zip City State Zip
Telephone 910-944-0881 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
E-mail Address
Current Street Address
City State Zip 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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Jamie Encinosa _ _ EVP of Operations
Type or print name Title or Authority
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Sign ure Date
I, Erivi S. ccleS --.a Notary Public of the County of MOOrP�
State of North Carolina, hereby certify that kILMIe, cJ �V1C"I V10S0i) appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my'qaggpcioptarial seal, this 3
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