NCC243524_FRO Submitted_20241114

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 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 and/
or fax information unavailable, place N/A in the blank.)
Part A.1. Project Name WaWa Trade Street and Western Boulevard
2. Location of land-disturbing activity: County Onslow City or Township City of Jacksonville
Highway/Street Western Blvd Latitude 34.779411 Longitude -77.395569
3. Approximate date land-disturbing activity will commence:11/11/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):2.37
6. Amount of fee enclosed: $ 300.00 . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rachel Steele E-mail Address [e-mail]
Telephone [phone] Cell# 803.465.3605 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
1079 Jacksonville LLC 305.682.0591
Name Telephone Fax Number
2950 SW 27th Avenue, Suite 300 2950 SW 27th Avenue, Suite 300
Current Mailing Address Current Street Address
Miami, FL 331.33 Miami, FL 33133
City State Zip City State Zip
10. Deed Book No.5432 Page No.695 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
Buffalo Construction, Inc. [e-mail]
Name E-mail Address
12700 Otto Knop Drive 12700 Otto Knop Drive
Current Mailing Address Current Street Address
Loiuisville, KY 40299 Louisville, KY 40299
City State Zip City State Zip
Telephone [phone] Fax Number 866.205.5259

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:
CSC [e-mail]
Name E-mail Address
2626 Glenwood Ave, Suite 550 2626 Glenwood Ave, Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone] 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:
CSC [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Ave, Suite 550 2626 Glenwood Ave, Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
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.
John unter Treasurer
Type • •rint ne Title or Authority
, 1� 11/12/2024
,i ature Date
Sarah Sheilley , a Notary Public of the County of Jefferson
Kentucky-_- John Hunter
State of ofaralcmaTab, hereby certify that 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 12th day of November 2024
/°A$1°Nei, Notary L..,
�` P12 & J� My commission expires 03 -a9 • a
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