NCC240066_FRO Submitted_20240109

Check if this project is ARPA-funded h
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 Hope Mills Freddy's
`/f 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 Cumberland City or Township Hope Mills
Highway/Street Hope Mills Road Latitude dec;ma,de reel 34.990839 -78.967181
e ) Longitude(decimaidegrees)
3. Approximate date land-disturbing activity will commence:January 2, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.95
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 Brad Taylor, PE E-mail Address btaylor@ moseleyrea.com
Phone: Office# 704-927-9224 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Custard Cats, LLC 785-370-0642
Name Phone: Office# Mobile#
530 McCall Rd, Ste 110
Current Mailing Address Current Street Address
Manhattan KS 66502
City State Zip City State Zip
10. Deed Book No. 11616 Page No. 254 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).
Custard Cats, LLC [e-mail]
Company Name E-mail Address
530 McCall Rd, Ste 110
Current Mailing Address Current Street Address
Manhattan KS 66502
City State Zip City State Zip
Phone: Office# 785-370-0642 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:
Incorp Services, Inc [e-mail]
Name of Registered Agent E-mail Address
176 Mine Lake Court, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Phone: Office# 800-246-2677 Mobile#
Rosa Mendoza
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.
Dylan Sultzer Chief Financial Officer
Type or print me Title or Authority
Signature Date
I, 1 A rick tan , a Notary Public of the County of P,}+"rrroNu�-
State of ro1iga, hereby certify that D4 lAA-1 S Lti11-7,t4- 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 o2 hd day of ND yq rrt}-.r 20 a 'J
Notary
Seal
My commission expires (4,41 Jao?4
NOTARY PUBLIC-Stets of Karma
RACNEL A MALLON
112217 .• WY APPL&ores criiL)-1 J2cL4/

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 66 Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.68(i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report,plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
XI The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate,and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
BI I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
NI If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
IX I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharge(s)and is enforceable in the
same manner as an individual permit.
Name of Project: Hope Mills Freddy's 11
Legally Responsible Organizational Entity: Go-stand Cats,LLC
Legally Responsible Person: Dylan Sultzer
Title of Legally Responsible Person: Chief Financial Officer
*Signature: lk --- Date: November 1,2023
*Print Name and Title of Si ned if Authorized
Individual Differs from Permittee:
Phone Number: 785-370 0642
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity,such as a president,secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV,Section B, Item(6)of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item(6)of the NCG010000 permit.