NCC232932_FRO Submitted_20231017

Check if this project is ARPA-funded
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 N/A in the blank.)
Part A.
1. Project Name Circle K - Expansion 2723205 Old US Hwy 52 & Hickory Tree Rd
*If this project involves American Rescue'Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Davidson City or Township Winston-Salem
HickoryTree Rd 35.968386 -80.223314
Highway/Street Latitude(decimal degrees) Longitude(decimal
3. Approximate date land-disturbing activity will commence:ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0'90
6. Amount of fee enclosed: $ 100 . 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 x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dennis Patterson E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Circle K Stores, Inc.
Name Phone: Office# Mobile#
PO Box 52085
Current Mailing Address Current Street Address
Phoenix AZ 85072
City State Zip City State Zip
10. Deed Book No. 2262 Page No. 2132 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).
Circle K Stores, Inc.
Company Name E-mail Address
1100 Situs Court, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27606
City State Zip City State Zip
Phone: Office# 919-774-6700 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 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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.
Meredith W. Rice, Jr. Vice President
Type or print name Title or Authority
Leddial'-/"1:1-c1/ 171 'ad
Signature Date
I ciao ✓! / 1 t -4 , a NotaryPublic of the Countyof \/ Atc ON
�
State of North Carolina, hereby certify that f} ►erect,f ll It)• E'Ce jr ► 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)CI- day of Ar^—( 2O 3
ROBIN F. ALFORD
Notary Public, North Carolina
Johnston County Not ry 4fijk-(2—
My Commission Expires
April 23, 2023
My commission expires ' 100=63 c t%

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:
Taylor Oil Company LLC
Name Phone: Office# Mobile#
4505 Country Club Rd; Suite 220
Current Mailing Address Current Street Address
Winston Salem NC 27104
City State Zip City State Zip
Deed Book No. 2590 Page No.2016 Provide a copy of the most current deed.
Landowner 3 of Record:
Hubbard Realty of WS Inc Taylor Development Group LLC
Name Phone: Office# Mobile#
1598 Westbrook Plaza Drive
Current Mailing Address Current Street Address
Winston Salem NC 27103
City State Zip City State Zip
Deed Book No.2590 Page No. 1826 Provide a copy of the most current deed
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. _ Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. _ _ 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#