HomeMy WebLinkAboutNCC231122_FRO Submitted_20230419FINANCIAL RESPONSIBILITY/OWNERSHIP 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 a -mall address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Sheetz Rebuild 399 Morrisville
2. Location of land -disturbing activity: County Wake city or Township
Morrisville
Highway/Street1600 Aviation Pkwy Latitude(dechaldegrees) 35.8554 Long itude(dedmal degrees) -78.7955
1 Approximate date land -disturbing activity will commence: May 1, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.69 AC
6. Amount of fee enclosed $1,050 . 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, afterwhich 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 ❑X No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tom AnaStasl E-mail Address tanastaS@SheetZ.Com
Phone: Office # N/A
Mobile # 919-437-9859
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Raleigh Durham International 919-840-7942 N/A
Name Phone: Office # Mobile #
PO box 80001 2800 Airport Blvd
Current Mailing Address Current Street Address
Raleigh NC 27623 Morrisville NC 27560
City State Zip City State Zip
10. Deed Book No. 1807 Page No. 0094 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).
Sheetz, Inc.
Company Name
5700 Sixth Avenue
Current Mailing Address
Altoona PA
City State
Phone: Office # N/A
tanastas@sheetz.com
E-mail Address
5700 Sixth Avenue
Current Street Address
16602 Altoona PA 16602
Zip City State Zip
Mobile # 919-437-9859
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A
Current Mailing Address
N/A
City State Zip
Phone: Office # N/A
N/A
N/A
Current Street Address
N/A
City State Zip
Mobile # N/A
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:
Corporate Service Company N/A
Name of Registered Agent
2626 Glenwood Avenue, Suite 500
Current Mailing Address
Raleigh NC 27608
City State Zip
Phone: Office # N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Mobile # N/A
ID #7348024
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 dame.
NIA
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:
Pabst Design Group, PA
Engineering firm or other consultant
Mark Phillips
Individual contact person (type or print)
mphillips@pabstdesign.com
E-mail Address
919-848-4399 919-81 Q-3716
Phone: Office #
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
Type or print name
C
Signafu-r
VP of Store Development
Title or Authority
Date
1, �� `' C Q_ , a Notary Public of the County of J6 16 l C
11��.n11y "�v�\.
State of-'N� .iina, here y certify that appeared personally
before me this day and being duly sworn acknowledged that the a4o e form was executed by him/her.
Witness my hand and notarial seal, this day of ' V-N , 20 =
Commonwealth of Pennsylvania - Notary seal
Alissa Morgret, Notary Public
Blair County
My commission expires October 23, 2024
Commission number 1384847 Notary
Member, Pennsylvania Association of Notaries
Seal My commission expires — - �+-j
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:
Phone: Office #
Mailing Address Current Street Address
City State
Deed Book No.
Landowner 3 of Record:
Mobile #
Zip City State Zip
Page No. Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address Current Street Address
Deed Book
Landowner 4 of Record:
Name
Current Mailing Address
State Zip
Page No,
City State
Deed Book No. Page
Landowner 5 of Record:
Name
Mobile #
City State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Street Address
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Mailing Address Gun
City State Zip City
Deed Book No. Page No.
Street Address
State Zip
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 Name E-mail Address
Current Malling Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
City State
Phone: Office #
Company Name
Address
Street Address
City
Mobile #
E-mail Address
Current Mailing Address Current Street
City State Zip City
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
State
Zip
Zip
City State Zip City State Zip
Phone: Office # Mobile #