NCC241357_FRO Submitted_20240502

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Culver's of Burlington, NC
1. Project Name
2. Location of land-disturbing activity: CountyAlamance City or Township Burlington
Highway/Street 3832 University Drive Latitude 36.0709 -79.5216
Longitude
3. Approximate date land-disturbing activity will commence:05/20/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial (Restaurant)
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): .71
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 ac=$900.00).
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 Joseph Dedick E-mail Address joe@campbellconstructic
Telephone [phone] Cell# 262-812-7327 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners).
SCCR Burlington, LLC 919-372-5610
Name Telephone Fax Number
808 Haddon Hall Dr. 3832 University Drive
Current Mailing Address Current Street Address
Apex, NC 27502 Burlington, NC 27215
City State Zip City State Zip
in, Deed Book No. Page No. Provide a copy of the most current deed.
Part b.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship.
the name of the owner or manager may be listed as the financially responsible party.
SCCR Burlington, LLC [e-mail]
Name E-mail Address
808 Haddon Hall Dr. 808 Haddon Hall Dr.
Current Mailing Address Current Street Address
Apex, NC 27502 Apex, NC 27502
City State Zip City State Zip
Telephone [phone] Fax Number

2. ta) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Adores
Current Mailing Address Current Street Address
City State Zip City State Zia
Telephone Fax Numc
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
-ssumed 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
r)v me unaer 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.
Eric- Roeske Owner
Type oint name ; Title or Authority
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0`1 3C/Zo 2 ci
Signature Date
t‘ a Notary Public of the County of LoCjh
State of North Carolina hereby certify that Y i(_ Pryk ,k4n O appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of Nri 1 I 20 a
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