NCC230576_FRO Submitted_20230314

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Ouality 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 I
Part A.
1 Project Name Lumberton CFA
2 Location of land -disturbing activity: County: Lumberton or Township Lumberton
HighwaylStreet 3400 North Elm Street Latituderd-,.,,,A ,Mve-0 34640558 Lon gituderd,.M„i *.uF.,.m -
79,007754
3 Approximate date land -disturbing activity will commence September 1, 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 2ac
6 Amount of fee enclosed $700.00. 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 ceding amount In addition,
the Express Permitting supplement is $250 per sere up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000-G0 (Example 8 10-acre application fee is $2,900) Checks should
be addressed to NCDEQ.
i7
8
9
Has an erosion and sediment control plan been filed? Yes I 1 Enclosed M No I 1
Person to contact should erosion and sediment control issues apse during land -disturbing activity
Name Todd VVilliams
Phone [phone]
E-mail Address Todd Williams(MCFACorp cam
Mobile
Landowner(s) of Record (attach accompanied page to list additional owners)
Name DOR FOODS INC DBA
Phone Office N
PO BOX 240U
Current Mailing Address
Mobile 0
3400 North Elm St
Current Street Address
Charlotte NC 26,224 Lumberton _ NC 28350
City State zip City State lip
10 Deed Book No Page No
Provide a copy of the most current deed

Part B.
1 Company lies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of a I i responsible parties on accompanied page ) if the company is a sote p roprrelor ship or d the landovnerrs,l is
an endividua$s) the name(s) of the ouner(sl may be Wed as the financinfly responsible party[iesl
Chick-Fil•A, Inc
Company Name
5200 Buffington Rd
Current Mailing Address
E-mail Address
5200 Buffnaton Rd
Current Street Address
Atlanta GA 30349 Atlanta GA 30349
City State Zip City State Zip
Phone Office #
Mobile #
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 forthe 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
5200 Buffington Rd
Current Mailing Address
Atlanta GA 30349
City State Zip
E-mail Address
5200 Buffington Rd
Current Street Address
Atlanta GA 30349
City State Zip
Phone- Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
M 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
New South Propertes of the Carolinas LLC wwhitleynnewsouthprop_com
Narne of Registered Agent E-mail Address
1518 E. Third St., Suite 300 1518 E. Thud St , Suite 300
Current Mailing Address Current Street Address
Charlotte NC 28204 Charlotte NC 28204
City State Zip City State Zip
Phone Office #
Mobile # [phone]
Will Whitley
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 Parry 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
Carter Engineering Consultants Inc
Engineering firm or other consultant
Mark Campbell
Individual contact person (type or print)
mark carteren ineenn .net
E-mail Address
Phone Office # 27 725-1200
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 lndividualts]
or his attorney-m-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
Type or print name
Signre
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Title or Authority
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Date
a Notary Public of the County of
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State of W.o�a. hereby certify that D t U.i 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 _id a y of 20 �a
,�•• DER IS '••
Notary
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