NCC242312_FRO Submitted_20240731

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville(Title 9, Chapter 8)before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Greenville,
Engineering Department. (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 Wawa -#6109 South Memorial and Thomas Langston Road
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Highway/Street S Memorial Dr Latitude(decimal degrees) 35.564069 Longitude(decimal degrees)-77.405751
3. Approximate date land-disturbing activity will commence: May 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.60 ac
6. Amount of fee enclosed: $ N/A . The application fee of$100.00 per acre or portion
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre
application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes x❑ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Josh White E-mail [e-mail]
Phone: Office# 757-490-1500 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Greenville 3600 Memorial WW, LLC 602-908-1424
Name Phone: Office# Mobile#
361 Summit Blvd, Ste 110
Current Mailing Address Current Street Address
Birmingham, AL 35243
City State Zip City State Zip
10. Deed Book No. 4396 Page No. 387 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. 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).
Independence Construction Co of VA [e-mail]
Company Name E-mail Address
301 Cleveland Place, Suite 103
Current Mailing Address Current Street Address
Virginia Beach, VA 23462
City State Zip City State Zip
Phone: Office# 757-490-1500 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:
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:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Suite 200 Same
Current Mailing Address Current Street Address
Raleigh NC 27615 Same
City State Zip City State Zip
Phone: Office# Mobile#
Karen Rozar
Name of Individual to Contact(if Registered Agent is a company)

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

(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.
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Type or print name tL Title or Authority
Signature Date
Ism N1 c_.1 C \ , a Notary Public of the.Caapty of V W—(010 k 7n7Pcl-t-
State otInrtb-C•ar-el+na, hereby certify that la,4„_, wcJcV_Lx.c, 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 OP"day of ..J,1/4--X\.SL , 20 2_4
II
otary
Seal
My commission expires
KIMBERLY TALLEY NICHOLS
Notary Public
Commonwealth of Virginia
Reg. 7685892
My Commission Expires February 29,2028