NCC232211_FRO Submitted_20230731

HENOEaNT).� FINANCIAL RESPONSIBILITY/OWNERSHIP FORM 2-H NERo ''"�
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 Henderson County Site Development Department. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Sign the original form in BLUE INK.
Part A.
1. Project Name QuikTrip #1148
2. Location of land-disturbing activity: County Henderson City Hendersonville
Highway/Street Upward Road Latitude 35.297761 Longitude 82.402383
Property Identification Number(s) PIN's 9588408795; 9588407844; 9588406934
3. Approximate date land-disturbing activity will commence: 02/15/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.22
6. Amount of fee enclosed: $ 1 700 . The application fee of $300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac = $2,900.00).
7. Has an erosion and sediment control plan been filed? Yes Y No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Duane Ensor E-mail Address densor@a fk-inc.com
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
QuikTrip Corporation
Name Telephone
PO BOX 3475
Current Mailing Address Current Street Address
Tulsa OK 74101
City State Zip City State Zip
10. Deed Book No. 3971 Page No.437-440 Provide a copy of the most current deed.
Part B. 3971 427-431
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
QuikTrip Corporation [e-mail]
Name E-mail Address
4705 South 129th East Avenue
Current Mailing Address Current Street Address
Tulsa OK 74134
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
JD Dudley
Name E-mail Address
3701 Arco Corporate Dr. Suite 150
Current Mailing Address Current Street Address
Charlotte NC 28273
City State Zip City State Zip
Telephone [phone]
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Matthew D. Miller Assistant Secretary
Type or rint name Title or Authority
<1M--X..x..k.) 0 A -1;la..._ 11/7/2022
Signature Date
Erin Raczkowski , a Notary Public of the County of Bexar
State of TEXAS hereby certify that Matthew D. Miller
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
Witness my hand and notarial seal, this 7th day of November 20 22
4`1P PiN* EAIN RACZKOWSKI ,(;4...........
e
�e's tart'Public, State of Texas
9l n.•+P� Comm. Expires 05-14-2023 Notary
Se;I Notary ID 132011838
' My commission expires :5 j q f Z 2.,