NCC242159_FRO Submitted_20240719

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Tractor Supply Co. - Lillington, NC
2. Location of land-disturbing activity: County Harnett City or Township Lillington
Highway/Street NC 210 S * US Hwy 401 Latltude(decimal degrees) 35.389543 Long itude(decimal degrees) 78'819087
3. Approximate date land-disturbing activity will commence:June 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5
6. Amount of fee enclosed $1 '750 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example:8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ. $500 for standard; $1,250
7. Has an erosion and sediment control plan been filed? Yes D Enclosed ❑x No D
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Keith Carter E-mail Address [e-mail]
Phone: Office# 513-849-8015 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Square at Lillington, LLC
Name Phone: Office# Mobile#
PO Box 10189 1131 B Military Cutoff Rd
Current Mailing Address Current Street Address
Wilmington NC 28404 Wilmington NC 28405
City State Zip City State Zip
10. Deed Book No.See Below Page No. See Below Provide a copy of the most current deed.
DB 1140 PG 482; DB 1135 PG 949; MB 2005, PG 687

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).
Reese Real Estate Lillington, LLC keith@a reeseredev.com
Company Name E-mail Address
1076 Summit Drive 1076 Summit Drive
Current Mailing Address Current Street Address
Middletown OH 45042 Middletown OH 45042
City State Zip City State Zip
Phone: Office# 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:
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)
(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:
Cogency Global Inc. 4 � (� (��LT�bba1 ,,cxm
Name of Registered Agent E-mail Address
212 South Tryon Street Suite 1000 212 South Tryon Street Suite 1000
Current Mailing Address Current Street Address
Charlotte NC 28281 Charlotte NC 2828
City State Zip City State Zip
Phone: Office# 866-775-0114 Mobile#
Christina Marasigan
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Quible & Associates, PC [e-mail]
Engineering firm or other consultant E-mail Address
Cathleen Saunders 2524918147 2522027112
Individual contact person (type or print) Phone: Office# Mobile#
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.
Keith Carter Manager
Type or int name Title or Authority
/// (---------- 3/az Vi-zo,v/
Sig ture Date
1, P -�-.,A S - N--..-...- , a Notary Public of the County of 141f111 614
NN 1�a � n
State of 9 cell a, hereby certify that tih C_Ctich 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 021 day of I .i,rc4 , 20ay
----- ----------
Notary
Seal My commission expires A14
,,,����I;H Hi�''.,,
-'° \1t1�/� S*+Andrew J.Ferguson,Attorney at law
a . s NOTARY PUBLIC-STATE 0f OH10
My commission has no expiration date
=V'*1 13= Sec.147.03 R.0