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HomeMy WebLinkAboutNCC233184_FRO Submitted_20231025 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name Dollar General - Pilot Mountain Store #30009 2. Location of land-disturbing activity: County Surry City or Township Pilot Mountain Highway/Street Mary Moore Drive Latitude(declmal degrees)36.3843 Longitude(declmal degrees)-80.4546 3. Approximate date land-disturbing activity will commence: November 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.92 acres 6. Amount of fee enclosed: $ 200 . 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 C7 Enclosed ❑ No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Joe Strickland E-mail Address jstrickland@teramore.net Phone: Office# Mobile# 704-224-7364 9. Landowner(s)of Record (attach accompanied page to list additional owners): Pilot Holistic Home & Garden, LLC 336-444-0125 Name Phone: Office# Mobile# 625 E. 52 Bypass 625 E. 52 Bypass Current Mailing Address Current Street Address Pilot Mountain, NC 27041 Pilot Mountain, NC 27041 City State Zip City State Zip 10. Deed Book No. 1847 Page No.862 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). Teramore Development, LLC jstrickland@teramore.net Company Name E-mail Address 214 Klumac Road Suite 101 214 Klumac Road Suite 101 Current Mailing Address Current Street Address Salisbury NC 28144 Salisbury NC 28144 City State Zip City State Zip Phone: Office# Mobile# 704-224-7364 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: Joe Strickland jstrickland@teramore.net Name of Registered Agent E-mail Address 214 Klumac Road Suite 101 214 Klumac Road Suite 101 Current Mailing Address Current Street Address Salisbury, NC 28144 Salisbury, NC 28144 City State Zip City State Zip Phone: Office# Mobile# 704-224-7364 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. Joe St( and Agent Type rint name Title or Authority Q nature Date I, 6.41Nt'21' 24 L , a Notary Public of the County of f u W 'Ai State of North Carolina, hereby certify that -TOE S i ✓t is tC t_A-N. appeared personally before me this day and being duly sworn acknowledged that the above forrrt was executed by him/her. Witness my hand and notarial seal, this 2 i day of 4 Li S i , 20 2_3 DANIEL R.ALMAZAN NOTARY PUBLIC Notary Rowan County _ North Carolina My commission expires J"a Z 8- 2 4 2 7 My Commission Expires June 28,2027 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: G&B Oil Co Inc. 336-835-3607 Name Phone: Office# Mobile# 227 N Elkin Drive 227 N Elkin Drive Current Mailing Address Current Street Address Elkin, NC 28621 Elkin, NC 28621 City State Zip City State Zip Deed Book No. 1 659 Page No. 181 Provide a copy of the most current deed. Landowner 3 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 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.