NCC230224_FRO Submitted_20230126

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 NIA in the blank.)
Part A.
1. Project Name Sheetz — S. Horner Blvd. & NC Hwy 42
Location of land -disturbing activity: County Lee City or Township Sanford
Highway/Street US 421 Bus — S. Horner Blvd Latitude(decimal degrees) 35.460 Longitude(decimal degrees)-79.146
3. Approximate date land -disturbing activity will commence: February, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.1 AC
6. Amount of fee enclosed: $ 400,00 . 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Downs E-mail Address bdownsAsheetz.com
Phone: Office # [phone] Mobile # _ [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J.R. Simpson & Donald R. Simpson
Name
503 Carthage St.
Current Mailing Address
9( 19)_774-6511
Phone: Office # Mobile #
_503 Carthage St.
Current Street Address
Sanford NC 27330 Sanford NC 27330
City State Zip City State Zip
10. Deed Book No. 303 Page No. 178 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible pady(ies).
Sheetz, Inc.
Company Name
5600 Sixth Avenue
Current Mailing Address
bdowns(a)sheetz.com
E-mail Address
5600 Sixth Avenue
Current Street Address
Altoona PA 16602 Altoona PA 16602
City State Zip City State Zip
Phone, Office # [phone] 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:
Corporation Service Company — ID# 7348024
Name of Registered Agent
2626 Glenwood Ave., Ste 550
Current Mailing Address
Raleigh NC 27608
City State Zip
Phone: Office #
E-mail Address
2626 Glenwood Ave. Ste 550
Current Street Address
Raleigh NC 27608
City State Zip
Mobile #
EJ Dealy
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 — ID# 7348024
Name of Registered Agent
2626 Glenwood Ave., Ste
Current Mailing Address
Raleigh NC 27608
City State Zip
Phone: Office #
E-mail Address
2626 Glenwood Ave., Ste 550
Current Street Address
Raleigh NC 27608
City State Zip
Mobile #
EJ Dealy
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.
Steven P. Augustine
Type or print name
Signature'
_ VP of Store Development
Title or Authority
Date
I, a Notary Public of the County of Rict k r
State of North Carolina, hereby certify that,) _v� kf, P A L c t,tS h�e appeared personally
before me this day and being duly sworn acknowledged that thdJabove form was executed by him/her.
Witness my hand and notarial seal, this 2 day of 2041_
COmmonwealth of Pennsylvania - Notary Seal
Alissa Morgret, Notary Public
Blalrcounty ('] i � 4AZ
Notary
ycommission expires October23, 2024
S al Commission number 1384847
Member, Penn Sylvania Association of Notaries My commission expires Io oa Y

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:
Simpson & Simpson II - Donald R. Simpson _ [phone]
Name Phone: Office # Mobile #
503 Carthage St. 503 Carthage St,
Current Mailing Address Current Street Address
Sanford NC 27330 Sanford NC 27330
City State Zip City State Zip
Deed Book No. 709
Landowner 3 of Record:
Page No, 648 Provide a copy of the most current deed.
Simpson & Simpson 11 --- David H. Simpson
Name
503 Carthage St.
Current Mailing Address
919 774-6511
Phone: Office #
503 Carthage St.
Current Street Address
Mobile #
Sanford NC 27330 Sanford NC 27330
City State Zip City State Zip
Deed Boom No. 709 Page No. 648 Provide a copy of the most current deed.
Landowner 4 of Record:
Donald R. Simpson,. Individual)
Name
503 Carthage St.
Current Mailing Address
[phone]
Phone: Office # Mobile #
503 Carthage St.
Current Street Address
Sanford NC 27330 Sanford NC 27330
City State Zip City State Zip
Deed Book No. 303 Page No. 178 Provide a copy of the most current deed.
Deed Book No. 709 Page No. 648 Provide a copy of the most current deed.
Landowner 5 of Record:
Barbara H. Simpson [phone]
Name Phone: Office # Mobile #
503 Carthage St. 503 Carthage St.
Current Mailing Address Current Street Address
Sanford NC 27330 Sanford NC 27330
City State Zip City State Zip
Deed Book No. 709 Page No, 648 Provide a copy of the most current deed.

Landowner 6 of Record:
David H. Simpson, Individually
Name
503 Carthage St.
Current Mailing Address
[phone]
Phone: Office # Mobile #
503 Carthage St.
Current Street Address
Sanford NC 27330 Sanford NC 27330
City State Zip City State Zip
Deed Book No. 303 Page No. 178 Provide a copy of the most current deed.
Deed Book No. 709 Page No. 648 Provide a copy of the most current deed.
Landowner 7 of Record:
Mary Elizabeth Barber [phone]
Name Phone: Office # Mobile #
503 Carthage St. 503 Carthage St.
Current Mailing Address Current Street Address
Sanford NC 27330 Sanford NC 27330
City State Zip City State Zip
Deed Book No. 709 Page No. 648 Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip
Zip
Zip City State Zip
Mobile #