NCC215973_FRO Submitted_20211101

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Highway 55 Burgers Fast Food Restaurant
Location of land -disturbing activity: County Onslow
City or Township Town of Richlands
Highway/Street Richlands Hwy (NC Hwy 24) Latitude 34.889 Longitude 77.549
Approximate date land -disturbing activity will commence: 12/06/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.94 Acres
6. Amount of fee enclosed: $ 500 + $130 = $630 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
7. Has an erosion and sediment control plan been filed? Yes No*�*' Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad Williams E-mail Address [e-mail]
Telephone [phone]
Cell # 615-294-4910 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NETLEASE ASSOC IATES-RICHLANDS, LLC 334-247-6219
Name
105 Tallapoosa Street, Suite 307
Current Mailing Address
Montgomery Alabama 36104
City State Zip
Telephone
Current Street Address
City
State
Fax Number
Zip
10. Deed Book No. Page No. 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.
NETLEASE ASSOC IATES-RICHLANDS, LLC
Name
105 Tallapoosa Street, Suite 307
Current Mailing Address
Montgomery Alabama 36104
City State Zip
[e-mail]
E-mail Address
Current Street Address
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:
National Registered Agents, Inc
Name
160 Mine Lake Ct. Suite 200
Current Mailing Address
Raleigh, North Carolina 27615-6417
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
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:
National Registered Agents, Inc
Name of Registered Agent
160 Mine Lake Ct. Suite 200
Current Mailing Address
Raleigh, North Carolina 27615-6417
City State
Telephone [phone]
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Freeland and Kauffman, Inc.
Engineering Firm or other consultant
Todd Simmons, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
864-672-3426
Telephone
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.
&1�
Type or print rvme Title or Authority
Signature Date
I, .A .0In CLG[ n , a Notary Public of the County of
A 104% mo,
State of Nek*-Gafe , hereby certify that SQ,M Soo 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 5 day of 20
ANGELA H. HENDERSON Notary
eal NOTARY PUBLIC
ALABAMA-STATE AT LARGE My commission expires
My Comm. Expires 07/13I2025