NCC222224_FRO Submitted_20220624

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 Lowes of Leland NC
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Location of land -disturbing activity: County Brunswick City or Township Leland
Highway/Street Gateway Boulevard Latitude 34-12-39.6 Longitude 78-1-12
Approximate date land -disturbing activity will commence: January 1, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.30 ac.
Amount of fee enclosed: $ 910 . 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:
Telephone,
Cell #
E-mail Addres
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Leland Town Center LLC 1-910-864-1125
Name Telephone Fax Number
2709 Thorngrove Ct. Suite 1 2709 Thorngrove Ct. Suite 1
Current Mailing Address Current Street Address
Fayetteville, NC 28303 Fayetteville, NC 28303
City State Zip City State Zip
10. Deed Book No. 4169 Page No. 156 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.
Lowe's Home Centers, LLC
Name E-mail Address
1000 Lowes Boulevard 1000 Lowes Boulevard
Current Mailing Address Current Street Address
Mooresville, NC 28117 Mooresville, NC 28117
City State Zip City State Zip
Telephone 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
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:
Corporation Service Company
Name of Registered Agent
327 Hillsborough Street
Current Mailing Address
Raleigh NC 27603
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
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.
Richard Goodman
Type or print name
- Signature
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Vice President
Title or Authority
2.1.22
Date
I, 2k" r,1 r_ \h fUr--'Z , a Notary Public of the County of III
State of North Carolina, hereby certify that E(Chcrd bio�jmnyi 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 I S$
Stephanie Valdez
NOTARY PUBLIC
Forstounty
North Carolina
My Commission Expires December 7, 2026
day of F 20 Z2
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