NCC243218_FRO Submitted_20241021

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 O'Reilly Auto Parts Greenville, NC (GE2)- Building Addition
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Highway/Street S. Memorial Drive Latitude(decimal degreesj35.594683Longitude(decimai degrees) -77.396129
3. Approximate date land-disturbing activity will commence: October 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.52 acres
6. Amount of fee enclosed: $ 200.00 . 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 ❑ Enclosed ISI No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ryan Lakey E-mail Address [e-mail]
Phone: Office# 417-851-5906 Ext: 65419 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
O'Reilly Automotive Stores Inc. 417-862-2674
Name Phone: Office# Mobile#
233 S. Patterson Ave. 233 S. Patterson Ave.
Current Mailing Address Current Street Address
Springfield, Missouri 65802 Springfield, Missouri 65802
City State Zip City State Zip
10. Deed Book No. 2564 Page No. 493-498 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 landowners)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
O'Reilly Automotive Stores, Inc. [e-mail]
Company Name E-mail Address
233 S. Patterson Ave. 233 S. Patterson Ave.
Current Mailing Address Current Street Address
Springfield, Missouri 65802 Springfield, Missouri 65802
City State Zip City State Zip
Phone: Office# 417-862-2674 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:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Ste 200 160 Mine Lake Ct, Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# 919 844 8360 Mobile#
Karen Rozar CIO CT Corporation System
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
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.
Phil Hopper Senior Vice President of Real Estate & Expansion
Type or print name Title or Authority
Signature Date
I, f 1�V1C(1,C'� C , a Notary Public of the County of (-/<<0A
11C:theri
State of , hereby certify that /77, 7 7�i�" Y 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 1-) day of SF all.k.X , 20 /1/
4 ATHENIA B AGEE 1 (tt,
NotaryPublic-NotarySeal
� Greene County-State of Missouri 1 Notary
Commission Number 22635072 / f/'.,
My Commission Expires Jun 20, 2026 I (� / /2O� (//
My commission expires ( rrr"'

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.

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#