NCC243441_FRO Submitted_20241106

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Dollar General Dunn
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Harnett City or Township Dunn
Highway/Street U.S. HWY 301 Latitude(decimal degrees)35.2771 Longitude(decimal degrees)-78.6279
3. Approximate date land-disturbing activity will commence: SEPTEMBER 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.26
6. Amount of fee enclosed: $300 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed ❑✓ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rhett Clodfelter E-mail Address Rhett@ rhetson.com
Phone: Office# 910-944-0881 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
E C Edgerton, Jr, LLC [phone]
Name Phone: Office# Mobile#
PO Box 398
Current Mailing Address Current Street Address
Dunn, NC, 28335
City State Zip City State Zip
10. Deed Book No. 1662 Page No.0482 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).
Rhetson Companies, Inc. [e-mail]
Company Name E-mail Address
2075 Juniper Lake Road 2075 Juniper Lake Road
Current Mailing Address Current Street Address
West End NC 27376 West End NC 27376
City State Zip City State Zip
Phone: Office# 910-944-0881 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:
Rhetson Companies, Inc. [e-mail]
Name of Registered Agent E-mail Address
2075 Juniper Lake Road 2075 Juniper Lake Road
Current Mailing Address Current Street Address
West End NC 27376 West End NC 27376
City State Zip City State Zip
Phone: Office# 910-944-0881 Mobile#
Jamie S. Encinosa, COO
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:
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)

(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.
Jamie S. Encinosa Chief Operating Officer
Type o rint na Title or Authority
Sign re Date
1,14%CO\Q- 0 ' OV-s , a Notary Public of the County of to,,' V.t +
State of North Carolina, hereby certify that Ct4. S. t\naSc•—. 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 '3. day of , 20 aLI
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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#

05/02/2024
To whom it may concern:
I, E C Edgerton, Jr, LLC, do hereby give permission for Rhetson Companies, Inc to perform
land disturbing activities for the construction of a new Dollar General on my property located
at the US 301 S Dunn,NC, 28334 being identified in Deed Book 1662 Page 0482. Land
disturbance activity will not begin until a deed transferring property ownership from E C
Edgerton, Jr, LLC, Seller, has been recorded or any other signed written agreement allowing
land disturbance activity from the seller has been executed.
E C. ic Lt,.L- 52\kc, /Ow n e r
Type or print name Title or Authority
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Signat Date
I, 3e..0e1.---1 . Sf-ektd , a Notary Public of the County of Gl- l
State of North Carolina, hereby certify that E C_ L d err0Y1 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, this3 day of Att. , 200R il
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