NCC242655_FRO Submitted_20240913

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 Environment and Natural Resources. (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 Tractor Supply
2. Location of land-disturbing activity: County Alamance City or Township Mebane
Highway/Street SR2187 (Wilson Rd) Latitude 36.069208 Longitude -79.268373
3. Approximate date land-disturbing activity will commence: July 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.90
6. Amount of fee enclosed: $600.00 The application fee of $100.00 per acre (rounded up to the
next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Hendon Properties, LLC E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hendon Tiller Mebane 3.0, LLC 404-262-7400
Name Telephone Fax Number
3445 Peachtree Rd NE#465 3445 Peachtree Rd NE#465
Current Mailing Address Current Street Address
Atlanta GA 30326 Atlanta GA 30326
City State Zip City State Zip
10. Deed Book No. RE 4425 Page No, 0336 Provide a copy of the most current deed. *Attached
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):
Hendon Tiller Mebane 3.0, LLC 404-262-7400
Name Telephone Fax Number
3445 Peachtree Rd NE#465 3445 Peachtree Rd NE#465
Current Mailing Address Current Street Address
Atlanta GA 30326 Atlanta GA 30326
City State Zip City State Zip

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
J. Charles I Hendon C ��-/ �«b744,i.ae-/rP.J, (d
Name of Registered Agent E-mail Address
3445 Peachtree Rd NE#465 3445 Peachtree Rd NE#465
Current Mailing Address Current Street Address
Atlanta GA 30326 Atlanta GA 30326
City State Zip City State Zip
Telephone [phone] 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.
rJ> member/manager
Type or print name Title or Authority
00,STAI
Date
I, DL n(l� S.�I a-%r . , a Notary Public of the County of TADoc310.6vi 11c..
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State of aa, hereby certify that j.Charles NC *'‘ j . 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 5kh day of jpr.L\ , 20 2-3
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Seal ` t/� t,16,�O ^•�
NOTARY My commission expires 3116124
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