NCC222275_FRO Submitted_20220712

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
Project Name: Bermuda Run CFA
2. Location of land -disturbing activity: County: Davie City or Township: Bermuda Run
Highway/Street: 260 NC-801 Latitude(decimai degrees) 36.009408 Longitude(decimal degrees)-80.443222
July
3. Approximate date land -disturbing activity will commence: Sept2m ber 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.7ac
6. Amount of fee enclosed $700.00. The Express Permitting application fee is a dual charge. The normal
fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition,
the Express Permitting supplement is $250 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks should
be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed M No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Thomas Guerard E-mail Address: [e-mail]
Phone: (404) 765 - 8000 Mobile: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name: Advance (Kinderton) UY LLC
Phone: Office # [phone]
8816 Six Forks Rd. Suite 201
Current Mailing Address
Mobile #
8816 Six Forks Rd. Suite 201
Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
10. Deed Book No.647 Page No.7
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible pa►ty(ies).
Chick-Fil-A, Inc.
Company Name
5200 Buffington Rd.
Current Mailing Address
E-mail Address
5200 Buffington Rd.
Current Street Address
Atlanta GA 30349 Atlanta GA 30349
City State Zip City State Zip
Phone: Office #
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
5200 Buffington Rd.
Current Mailing Address
Atlanta GA 30349
City State Zip
Phone: Office #
E-mail Address
5200 Buffington Rd.
Current Street Address
Mobile #
Atlanta GA 30349
City State Zip
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
New South Properties of the Carolinas. LLC wwhitleye-newsouthprop.com
Name of Registered Agent E-mail Address
1518 E. Third St., Suite 300 1518 E. Third St., Suite 300
Current Mailing Address Current Street Address
Charlotte NC 28204 Charlotte NC 28204
City State Zip City State Zip
Phone: Office #
Mobile # [phone]
Will Whitley
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If 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:
Carter Engineering Consultants, Inc
Engineering firm or other consultant
Mark Campbell
Individual contact person (type or print)
mark c5carterengineering.net
E-mail Address
Phone: Office # [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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
.- o—riprint name
v fLPsf �-r
Title or Aut orit
Date
I, , a Notary Public of the County of
State of Qlion-a�, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of A MAY 20 ?'e-)
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Notary
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Phone: Office # Mobile #
Name
Current Mailing Address
Current Street Address
City
Deed Book No
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
City
Phone: Office #
Company 4 Name
Current Mailing Address
City
Phone: Office #
Company 5 Name
Current Mailing Address
City
Phone: Office #
State Zip
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
E-mail Address
Current Street Address
State Zip City State
Mobile #
Zip