NCC220804_FRO Submitted_20220221

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 NIA in the blank.)
Part A. FamilyDollar Tree
1. Project Name
2. Location of land -disturbing activity: CountyYadkln City or Township East Bend
Highway/Street NC 67 Bypass Latitude 36.2149 Longitude-80.5053
3. Approximate date land -disturbing activity will commence: March 15, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Commercial Retail Store
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.7 ac
6. Amount of fee enclosed: $ $200.00 . 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? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Sanders Chapman E-mail Address [e-mail]
Telephone [phone] Cell # 843-340-4875 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
linda Poindexter 8544294081
Name Telephone Fax Number
4373 HUNTING BOW TRAIL
Current Mailing Address Current Street Address
MYRTLE BEACH SC 29579
City State Zip City State 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.
TRC East Bend, LLC [e-mail]
Name E-mail Address
656 ellis oak ave
Current Mailing Address Current Street Address
Charleston, SC 29412
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:
Registered Agent Solutions, Inc
Name E-mail Address
176 Mine Lake Court Ste 100
Current Mailing Address Current Street Address
Raleigh NC 27615
City
Telephone
State Zip 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:
TRC East Bend, LLC [e-mail]
Name of Registered Agent
656 ellis oak ave
Current Mailing Address
Charleston, SC 29412
City State
Telephone [phone]
E-mail Address
Current Street Address
Zip City State Zip
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.
TRO "zC- 5wir GP_,Vif, CGG
By: TRC anagement, LLC ; its Manager
By: J ffr J. 7'bqon ; i ent
Date' A122
a Notary Public of the County ofC,�1Q�`�flii
State of ++&4hrCarolina, hereby certify that,_e \Rappeared
personally before me this day and being duly swor acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this �L]�j_day of .20
Notary �.
Seal ,,11 '' JJ ^^ �� 22 I
My commission expires J�-
DONNA K GRAU
NoWy ft* State of South Canjne
My Commission Expires 114=1