NCC233280_FRO Submitted_20231102

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville(Title 9,Chapter 8)before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Greenville,
Engineering Department. (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 Royal Farms Store 494
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Highway/Street N.C.S.R 1200 Latltude�decimaidegrees)35.606388Longitude(decimaidegrees)-77.421941
3. Approximate date land-disturbing activity will commence: 2/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed: $ . The application fee of$100.00 per acre or portion
thereof (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 ❑ Enclosed V No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 1941i / i'ouSG E-mail Address ASfrowaL& rG(ok- c. G41n1
Phone: Office# 80 it- Yi4'o 7 K v Mobile# 80 q—y 7—O 7 V 7
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Rebkee Partners Stantonsburg, LLC 804-291-7947
Name Phone: Office# Mobile#
2800 Patterson Ave. Suite 200 SRMf✓ A-s I�'1AIGl�G-
Current Mailing Address Current Street Address
Richmond, VA 23221
City State Zip City State Zip
3516
10. Deed Book No. Page No. 395 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).
(-5 ).5 Ar .s,
[e-mail]
Company Name E-mail Address
2800 Patterson Avenue, Suite 200 Same as mailing
Current Mailing Address Current Street Address
Richmond, VA 23221
City State Zip City State Zip
Phone: Office# 804-419-0740 Mobile# SOLI—(11 q—O 7q7
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:
r rs/eyed Gn7� /4
Nam�f Registered A ent E-mail Address
"/030 wake /re5 f ,ed $/e 3Yr 5/ic 4s Aka AIc-
Current Mailing Address Current Street Address
le(q h tiG 027tooq
City I State Zip City State Zip
Phone: Office# 1 19 'god 'II v 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.
Dal;e/ 14r4P#- Ai4 n41 e r
Type or print nine I Title or Authority
0-5- Zio 2�,
Signat re. 7.2%----) Date
I, A in.n.otR)� �c,14 O'l , a Notary Public of the County of lie,.r,'c 0
�1�rr�qq�,n io.
State of 4+6�efeW� hereby certify that L,,n,,ti pW appeared personally
before me this day and being duly sworn acknowledged that the abov orm was executed by him/her.
Witness my hand and notarial seal, this c544 day of OG-4rt'be_r , 20 Z7.
0aryA.A.A.4.1„7" --7'R
Seal
My commission expires Liu
Q-,
NOTARY
PUBLIC
REG.#715050
= MY COMMIS,UN Q =
7- 0p• EXPIR S
07/3112024 6.-:
1.
',,,� 4 ,'o �CA11.TI-1 O� N`'
iiiI111111111 ii"

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:
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 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.

Continued from Item 9 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#

Commonwealth of Virginia
State Corporation Commission
Office of the Clerk
Entity ID:11312118
Filing Number:2111303916310
Filing Date/Time:11/30/2021 03:52 PM
Effective Date/Tlme:11/30/2021 03:52 PM
Bill( 1LII '- "al '.'I,gl 1U.),
Entity Name: Stantonsburg Partners, LLC Entity Type: Limited Liability Company
I,of lot •,,<n
Industry Code: 0-General
Perpetual(forever)
RA Type: Entity Locality: RICHMOND CITY
RA Qualification: N/A
Mid-Atlantic Property
Name: Management Company, Email Address: [e-mail]
L.L.C.
The company's initial registered office address,including the street and number,if any,which is identical to the
business office of the initial registered agent, is:
Registered Office 2800 Patterson Ave Ste
Address: 200,Richmond,VA,23221 - Contact Number: N/A
1762,USA
ddress: Ruth Schott,2800 Patterson Ave Ste 200,Richmond,VA,23221 -1762,USA
Management Structure:Manager-Managed
Signature Information
Date Signed: 11/30/2021
Executed in the name of the limited liability company by:
Printed Name Signature Title
Daniel L Hargett Daniel L.Hargett Organizer

Paul Sprouse
From: Ruth Schott
Sent: Wednesday, October 5, 2022 12:12 PM
To: Paul Sprouse
Subject: FW:Thank You for Your Order with NCRA Registered Agent LLC
Ok, we are registered in NC. I found the entity we had set up. It was Stantonsburg Partners, LLC,so I registered that
name.
REBKEE
RUTH SCHOTT
[e-mail]
2800 Patterson Ave.Suite 200,Richmond,VA 23221
804-419-0749
rebkee.com
From: [e-mail]<[e-mail]>
Sent: Wednesday, October 5, 2022 12:02 PM
To: Ruth Schott<[e-mail]>
Subject:Thank You for Your Order with NCRA Registered Agent LLC
You must use this registered agent name:
Registered Agents Inc
Your registered office address:
4030 Wake Forest Road, STE 349
Raleigh , NC 27609
Hello Ruth,
Thank you for placing your order with us.
Your Order Details:
Order placed on Oct 05, 2022
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NCRA Registered Agent LLC
4030 Wake Forest Rd STE 349
Raleigh, NC 27609
T: 919-400-4138
E: [e-mail]
W: www.northcarolinaregisteredagent.net
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