NCC223729_FRO Submitted_20221109

TIMMONS GROUP
September 19, 2022
Mr. Randall Jones, Jr., PE
NC Dept. of Environmental Quality
Division of Energy, Mineral and Land Resources
943 Washington Square Mall
Washington, NC 27889
RE: Erosion and Sediment Control Permit
Starbucks — Ehringhaus
Timmons Project No. 41389.061
Dear Mr. Jones:
1805 West City Drive p 252.621.5030
Unit E F 252.562.6974
Elizabeth City, NC 27909 www.timmons.com
Enclosed for your review and approval, please find the following items:
1. The original and (2) copies of the Financial Responsibility Form.
2. Three (3) copies of the plans for the above referenced project.
3. Three (3) copies of the drainage narrative.
4. A check in the amount of $200.00 for the required fee.
If you have any questions or require any additional information, please do not hesitate to contact me at
[phone].
Sincerely,
Timmons Group 1
vY b 0 - ` J a,—b�
vV 0
Kimberly D. Hamby, PE
Sr. Project Manager
cc: file
Vanguard Ventures
ENGINEERING I DESIGN I TECHNOLOGY

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 Starbucks - Ehringhaus
2 Location of land -disturbing activity: County Pasquotank City or Township Elizabeth City
Ehringhaus Street 36.2946-76.2399
Highway/Street LatltUde(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: 11 /01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.)- commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1.2
00
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 ❑x Enclosed ❑x No ❑
I-]
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George Venters E-mail Address [e-mail]
Phone: Office # 919.459.2602 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Vanguard Ventures IV, LLC 919.459.2601 919.524.2020
Name Phone: Office # Mobile #
3825 Barrett Drive, Suite 100 3825 Barrett Drive, Suite 100
Current Mailing Address
Raleigh, NC 27609
City
Current Street Address
Raleigh, NC 27609
State Zip City
10. Deed Book No. 1460 Page No, 658
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).
Vanguard Ventures IV, LLC
Company Name
3825 Barrett Drive, Suite 100
Current Mailing Address
Raleigh, NC 27609
City State
Phone: Office # 919.459.2601
[e-mail]
E-mail Address
3825 Barrett Drive, Suite 100
Current Street Address
Raleigh, NC 27609
Zip City State
Mobile # [phone]
Zip
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:
George T. Barnes
[e-mail]
Name of Registered Agent
E-mail Address
3825 Barrett Drive, Suite 100
3825 Barrett Drive, Suite 100
Current Mailing Address
Current Street Address
Raleigh, NC 27609
Raleigh, NC 27609
City State
Zip City State Zip
Phone: Office # 919.459.2602
Mobile # [phone]
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:
E-mail Address
Name of Registered Agent
Current Street Address
Current Mailing Address
Zip City State Zip
CEty State
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.
George T. Barnes
Type or pri�
Signature
Registered Agent, Vanguard Ventures IV, LLC
Title or Authority
Date '
I, k Lrtla
Y rI E a Notary Public of the County of tVn' /
State of North Carolina, hereby certify that Lc- - r� C- appeared personally
before me this day and being duly sworn acknowledded that the above form was executed by him/her.
Witness my hand and notarial seal, this day of r1a 2g�
Shernann N. Hepps /)
NOTARY PUBLIC
Wake County otary
Seallonh Carolina S
My Commission Expires March 15, 2026 My commission expires

VANGUARD VENTURES IV LLC
3825 BARRETT DR SUITE 100 q
RALEIGH, NC 27609 DATE q U
q q�
005000
PAY TO IMF
ORDER OF
NORTH STATE BANK
MENTO eywoV1 F,00" I (swwdc%-6L) J.
l:053 L L 2356l: 000 L 233 27 L4ii' 00500
$ 200,00
DOLLARS