NCC240103_FRO Submitted_20240119

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Corporation Service Company [e-mail]
Name E-mail Address
2626 Glenwood Ave,Suite 550 Same as mailing address
Current Mailing Address Current Street Address
Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Bridget Katu.zlcy-, �u ilzkr• l AVP, Real Estate
Typ or print name 1 Title or Authority
I � /D• /ivrC • 3
L
Signa re Date
I, 1 o, n( / AIt'i1tie_ , a Notary Public of the County of RX,elc°/ARirm-
oA
State of Ned r£erefina, hereby certify that •6Ady 71 / ]ze t z,/C 4appeared
personally before me this day and being duly sworn acknowl6dged that the above form was
executed by him.
Witness my hand and notarial seal, this / /L day of 0 ht ix.- , 20 ,.-?3
DONNA M WARNER
Notary PublicA.--A4.,clidrHaA-41--c---,
N¢ :, Maricopa County,Arizona
s,�04 My Comm.Expires 04 06 24 Notary
= eal Commission No.581521
My commission expires `''L 6 .df ws I

JOHNSTON COUNTY 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
Johnston County Department of Public Utilities. (Please type or print and, if the question is not applicable or
the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Discount Tire-Garner,NC
2. Location of land-disturbing activity: City or Township Unincorporated Johnston County
Highway/Street NC 42 West Latitude 35.612076 Longitude -78.555983
3. Approximate date land-disturbing activity will commence: 12/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1.5
6. Amount of fee enclosed: $ 800.00 . The application fee of$400.00 per acre(rounded
up to the next acre)is assessed for the first 8 acres and an additional $125 per acre for each additional
acre(rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kelly Wagoner E-mail Address [e-mail]
Telephone [phone] -Cell# 770-500-4973 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Aldi(N.C.)L.L.C. 855-955-2534
Name Telephone Fax Number
6801 Aldi Way 5142 NC-42
Current Mailing Address Current Street Address
Petersburg,VA 23803 Garner,NC 27529
City State Zip City State Zip
10. Deed Book No. 5598 Page No. 152-156
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Halle Properties,L.L.C. [e-mail]
Name E-mail Address
20225 N Scottsdale Rd Same as mailing address
Current Mailing Address Current Street Address
Scottsdale,AZ 85255
City State Zip City State Zip
Telephone [phone] Fax Number