NCC222970_FRO Submitted_20220819

FINANCIAL RESPONSIBILITWOWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name SHEETZ SURRY COUNTY
2. Location of land -disturbing activity: County SURRY City orTownship MT.AIRY
Highway/Street US HWY 68 Latitude(declmaldegrees) 36.4830 Long itude(decfmaldegrees) -80.7549
3. Approximate date land -disturbing activity will commence: APRIL 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): COMMERICAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.78
6. Amount of fee enclosed $3,300 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Wes Hall E-mail Address [e-mail]
Phone: Office # 919-896-2019 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BGSS INVESTMENTS LLC
Name
PO BOX 1545
Current Mailing Address
MOUNT AIRY NC 27030
City State Zip
Phone: Office # Mobile #
Current Street Address
City State Zip
10. Deed Book No. 01543 Page No. 0225 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 sate 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).
Sheetz, Inc. [e-mail]
Company Name E-mail Address
5700 Sixth Avenue 5700 Sixth Avenue
Current Mailing Address Current Street Address
Altoona PA 16602 Altoona PA 16602
City State Zip City State Zip
Phone: Office # 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:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
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:
Corporation Service Company
Name of Registered Agent E-mail Address
2626 Glenwood Ave, Suite 550
Current Mailing Address
Raleigh NC 27608
City State Zip
Phone: Office # 866-403-5272
2626 Glenwood Ave, Suite 550
Current Street Address
Raleigh NC 27608
City State Zip
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
(d) If 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:
STIMMEL
Engineering firm or other consultant
Bennett
Individual contact person (type or print)
[e-mail]
E-mail Address
3367231067
Phone: Office #
3363028180
Mobile #
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.
Steven P. Augustine VP of Store Development
Type or print n Title or Authority
Sign ure Date
c,_ f -(� k%>: c%L,, a Notary Public of the County of ic{
State of Nert#-Gamlit'ta, hereby certify that'*'=�,., ri. t 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 day of I )'I„ , -r, , 20 ) ..)
Seal
`'-'W wea,;n of Pennsylvania • Notary Seal
.ESSICAA PFULSTUCKER • Notary Public
Blair County
y Commission Expires October 18, 2025
LMA
5
Commission Number 1279750
Notary
My commission expires I �_+I { �) L„)