NCC233600_FRO Submitted_20231215

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 NCG01 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 Atkinson Dollar General
*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 Fender City or Township Atkinson
Highway/StreetWest Church Street Latitude(decimal degrees) 34.52438 Longitude(decimal degrees)78.17612
3. Approximate date land-disturbing activity will commence: December 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.82 Acres
6. Amount of fee enclosed: $ 200.00 . 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 IX No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Brandon Smith [e-mail]
Name E-mail Address
Phone: Office# 910-944-0881 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Patricia A. Howley 845-742-0480
Name Phone: Office# Mobile#
181 Royal Tern Drive
Current Mailing Address Current Street Address
Hampstead NC 28443
City State Zip City State Zip
10. Deed Book No. 4745 Page No. 2301 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).
Rhetson Companies, Inc [e-mail]
Company Name E-mail Address
2075 Juniper Lake Road 2075 Juniper Lake Road
Current Mailing Address Current Street Address
West End NC 27376 West End NC 27376
City State Zip City State Zip
Phone: Office# 910-944-0881 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:
Rhetson Companies, Inc [e-mail]
Name of Registered Agent E-mail Address
2075 Juniper Lake Road
Current Mailing Address Current Street Address
West End NC 27376 West End NC 27376
City State Zip City State Zip
Phone: Office# 910-944-0881 Mobile#
Jamie S. Encinosa, COO
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.
Jamie S. Encinosa Chief Operating Officer
Ty or print ame . Title or Authority
�) 0 las�jam. 3
i ature Date
IN tCokCb. Nose 0 , a Notary Public of the County of Q"Y i' 2 l
State of North Carolina, hereby certify that 3ainau S • Ev cA 110 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 day of7 , 20
,,,,,,,,,,,,,,,,,, 44,-CA ' 6-aLle_A -
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Z,:AoTA/,, \ My commission expires �� �- (�a�
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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 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#

September 6ih,2023
To whom it may concern:
I,Patricia A.Howley,do hereby give permission for Rhetson Companies,Inc to perform land
disturbing activities for the construction of a new Dollar General on my property located at the
intersection of NC 53 and NC 1218 near Atkinson,NC being identified in Deed Book 4745
Page 2301.Land disturbance activity will not begin until a deed transferring property
ownership from Patricia Howley,Seller,has been recorded or any other signed written
agreement allowing land disturbance activity from the seller has been executed.
Tc Yi CA 6 , 1--0 tiO -2� 0u9 i'1
Type or print name Title or Authority
/41/14katet o`�//3/d 3
Signature Date
I, h11 s A to L. /"`�'f e-- ,a Notary Public of the County of 0n510GJ
State of North Carolina, hereby certify that f a.t``ram/- /710 Li de--)" appeared
personally before me this day and being duly sworn acknowledged that the alcove form was executed
by him.
h
Witness my hand and notarial seal,this ; day of 5 cric ,20�� 3
7/a--("6:
WILLIAM L. MOISE Notary
Sehlotary Public
North Carolina My commission expires /''' 3' fi/ L.a. -7
Onslow County