NCC240032_FRO Submitted_20240105

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 Shelby Retail Store
2. Location of land-disturbing activity: County Cleveland City or Township Shelby
Highway/Street New Prospect ChurchRd Latitude(declmal degrees) 35.3314 Longltudeldecimal degrees)-X 1.4996
3. Approximate date land-disturbing activity will commence: Fall 2023
4. Purpose of development(residential,commercial,industrial, institutional,etc.) Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.60
(A) �✓�� . Amount of fee enclosed: $ 200 The application fee of$100.00 per acre (rounded
40 c1-" up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Lp�rt�.5�i Checks should be addressed to NCDEQ.
,t„t.k
?L"on 7 Has an erosion and sediment control plan been filed? Yes 0 Enclosed a No 0
o�
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Robert Broadway So
ay E-mail Address Car vi_ .1 Le_3
Phone: Office# 533-7287 Mobile# (ast.) (07 41- lc/
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Bulldog Property Holdings LLC
Name Phone: Office# Mobile#
419 Dick Spanger Rd 419 Dick Spanger Rd
Current Mailing Address Current Street Address
Shelby NC 28150 Shelby NC 28150
City State Zip City State Zip
10. Deed Book No. 1887 Page No. 1750 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).
The Broadway Group of Alabama, LLC carson.styles a broadwaygroup.net
Company Name E-mail Address
216 Westside Square 216 Westside Square
Current Mailing Address Current Street Address
Huntsville AL 35801 Huntsville AL 35801
City State Zip City State Zip
Phone: Office#[phone] Mobile#[phone]
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:
Douglas Pearson _ [e-mail]
Name of Registered Agent E-mail Address
611 N Church Street Ste 9 611 N Church Street Ste 9
Current Mailing Address Current Street Address
Hendersonville NC 28792 Hendersonville NC 28792
City State Zip City State Zip
Phone: Office#[phone] Mobile
NA
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:
Douglas Pearson dougapearsonlawfirmnc.com
Name of Registered Agent E-mail Address
611 N Church Street Ste 9 611 N Church Street Ste 9
Current Mailing Address Current Street Address
Hendersonville NC 28792 Hendersonville NC 28792
City State Zip City State Zip
Phone: Office#[phone] Mobile
NA
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.
Robe Member
Typ 'nt name Title or Authority
Signature Date
I, Corot 5411e5- , a Notary Public of the County of kt,A
A�,b4w<..
State of-North•G oiirre, hereby certify that 1Z e l Er 0 Atlude.,1 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 20i' day of Sce 1vc, , 20 y3
4/tkku_)Lbl
,yoN sTy4 i,�� Notary J
\
\•-; 0•�. •��� J� My commission expires
NOTARY
•
• _.� _
UBLI MY COMMISSION EXPIRES 6.8-2026