NCC216691_FRO Submitted_20211209

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Dollar General
Location of land -disturbing activity: County Nash City or Township Middlesex/Samaria
Highway/Street W NC 97
Latitude N35-51-34 Longitude W78-10-35
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.77
6. Amount of fee enclosed: $130.00 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George T. Barnes -Glandon Forest Equity, LLC E-mail Address [e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Morgan Properties, LLC [phone]
Name Telephone Fax Number
5904 Morgan Rd.
Current Mailing Address Current Street Address
Bailey NC 27807
City State Zip City State Zip
10. Deed Book No. RE 2921 Page No.215 Provide a copy of the most current deed. *Attached
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Glandon Forest Equity, LLC [e-mail]
Name E-mail Address
3825 Barrett Dr., Suite 100
Current Mailing Address Current Street Address
_Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number (19) 459-2604

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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number.
State Zip
(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:
Sherri Heppe Glandon Forest Equity, LLC
Name of Registered Agent
3825 Barrett Dr., Suite 100
Current Mailing Address
she ppsAvanguardpg.com
E-mail Address
Current Street Address
Raleigh, NC 27609
City State Zip City
State Zip
Telephone [phone] Fax Number [phone]
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.
Type or pri
Signature
member/manacier
Title or Aut ority
l
Date
I, 4hLq M1Cdj ►`JO,v1S , a Notary Public of the County of
State of North Carolina, hereby certify that QDe.Gk-C>'t I RJGY0is appeared
personally before me this day and being duly sw rn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this r O day of NovexvnACur , 20 ZA
FAY
S. :-, ' s
Seal z to �® KILI
Notary..
My commission expires IUD-o5-- 2?j