NCC232531_FRO Submitted_20230823

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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name Dollar General Henderson Vicksboro Rd
2. Location of land-disturbing activity: County Vance City or Township_Warrenton
Highway/Street Vicksboro Rd Latitude 36.315304 Longitude -78.362736
3. Approximate date land-disturbing activity will commence: August 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.23
6. Amount of fee enclosed: $ _300 . 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).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John Parker E-mail Address iohn(a�rhetson.com
Telephone [phone] Cell # 910-690-0155 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rhetson Companies, Inc 910-944-0881
Name Telephone Fax Number
2075 Juniper Lake Rd
Current Mailing Address Current Street Address
West End NC 27376
City State Zip City State Zip
10. Deed Book No. 1158 Page No. 300 Provide a copy of the most current deed.
Part B.
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.
eA' M C (1,1(1.(P, nc_ pef @ r Int,-Fsvh. cow
Name / E-rrlail Address
(;u Akiu.02,r LoX-' kOk
Current Mailing Address Current Street Address
1ndt N g33210
City State Zip City State Zip

Telephone CM) - I' 114- Fax Number `"I Io -"I144- VC�O a
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 Fax Number
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.
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Signat j).-
Date
I, N \COO f D. O 1.Q_ _ , a Notary Public of the County of -Aar kQ '
State of North Carolina, hereby certify thatJQ.M,I-t S �C V C O'1 OSC-._ 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 \3A4N. day of Jlik., , 20 cD3
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