NCC215298_FRO Submitted_20211005

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 AutoZone Burnsville NC1204
2. Location of land -disturbing activity: County Yancey City or Township Town of Burnsville
Highway/Street 701 West Main St. Latitude 35.91278 N Longitude-82.31333 W
3. Approximate date land -disturbing activity will commence: 4-12-21 +/-
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.1 Ac. +/-
$130 application fee
6. Amount of fee enclosed: $ $500 express review The application fee of $65.00 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Rex Storer (AutoZone) E-mail Address [e-mail]
Telephone [phone] Cell # 901-288-1165 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AutoZone Development, LLC
901495-6736
Name
Telephone Fax Number
123 S. Front Street
123 S. Front Street
Current Mailing Address
Current Street Address
Memphis TN 38103
Memphis TN 38103
City State Zip
City State Zip
10. Deed Book No. 56 Page No. i `E - 74R 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 may be listed as the financially responsible party.
AutoZone Stores LLC
[e-mail]
Name
E-mail Address
123 S. Front Street
123 S. Front Street
Current Mailing Address
Current Street Address
Memphis TN 38103
Memphis TN 38103
City State Zip City State
Zip

Telephone [phone] Fax Number
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:
CT Corporation System
Name
160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh NC 27615-6417
City State Zip
Telephone
E-mail Address
160 Mine Lake Ct Ste 200
Current Street Address
Raleigh NC 27615-6417
City State Zip
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:
CT Corporation System
Name of Registered Agent
160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh
City
Telephone
E-mail Address
160 Mine Lake Ct Ste 200
Current Street Address
NC 27615-6417 Raleigh
State Zip City
Fax Number
NC 27615-6417
State Zip
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.
Tlrnothy A Goddard Vice F%Wderd
Typ or print name
QWO
nature k &*
Title or Authority
Date
I, w , a Notary Public of the County of U IYGUJ
State of ins; hereby certify that Timothy I Goddard appeared
personally before me this day ARd beiRg-�'-acknowledged that the above form was executed
by him. X5' /
Witness my hand and notarial seal, this A ' day of �(1 20 O l
SMITH
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al �a� Ply My Commission Expires
�1V '01\ �\0 2 My commission expires November 21, 2021
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