NCC216409_FRO Submitted_20211116

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 riot applicable or the e-mail and/or fax
information unavailable, place N/A in the blank.)
Part A.
1. Project Name_ Dollar General - Jonesville
2. Location of land -disturbing activity: County Yadkin City or Township Hamptonville
Highway/Street 5517 US 21 Hwy Latitude 36.194231 Longitude-80.809752
3. Approximate date land -disturbing activity will commence: Feb 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.61 acres
6. Amount of fee enclosed: $ 130+500 = 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Joe Strickland
Telephone [phone]
Cell #
E-mail Address [e-mail]
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Teramore Development, LLC
Name
PO Box 6460
Current Mailing Address
Thomasville, GA 31758
City State
10. Deed Book No. 1337
Telephone
165 Big Star Drive
Current Street Address
Fax Number
Thomasville, GA 31758
Zip City
Page No. 620
State
Zip
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.
Teramore Construction, LLC
Name
214 Klumar, Road Suite 101
Current Mailing Address
Salisbury NC 28144
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip
City State Zip
Telephone
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:
E-mail Address
Name of Registered Agent
Current Street Address
Current Mailing Address
City State Zip
City State Zip
Telephone
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:
BREC, PA
[e-mail]
Engineering Firm or other consultant
E-mail Address
Justin Church, PE
336-844-4088 _
Individual contact person (type or print)
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.
Joe Str' `kland Member
Type or Title or Authority
Date 7 Z�17
"/ /4'Vr51 A.
a Notary Public of the County of
State of North Carolina, hereby certify that 5V 1z S f 2L GV, appeared personally
before me this day and being duly sworn acknowledged that the above fcr6) a,� s executed by him.
Witness my hand and notarial seal, this o7'1 rOday of 0—
DANIEL R ALMA7AN
NQ��,�tY PUBLIC
Fi'En County
North Carolina
tiny Commission n Expires June 25, 2022
20 Z
Notary
My commission expires V Nk Z S,, 2 0 2 z