NCC223598_FRO Submitted_20221021

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. Family Dollar
1. Project Name
2. Location of land -disturbing activity: CountyAnson
City or Township Ansonville
Highway/Street Waddell St Latitude 35.103320 Longitude 80.107882
3. Approximate date land -disturbing activity will commence: Dec 1 , 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.43
6. Amount of fee enc€osed7 $ 130 . 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 Yes
S. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Will Stronach
E-mail Address [e-mail]
Telephone[phone] Cell # 919-270-1750
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional own/ers):
&isy
Name Telephone Fax Number
6 4z I f I olvAk4 4
Current Mailing Address
City State Zip
10. Deed Book No. �4'� Page No._
rf
Current Street Address
�r
City 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.
Sp �,1,�.C� ilk �`�,rran��. u���,��s . �...�► -
Name E-mail A ress
400A trr4 ht. lob - -
Current Mailing Address
Rita sf ' A 21601
city State Zip
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Current Street Address
City State Zip
Telephone AtRI 27V 1 ? S O Fax Number OK4, av'L-
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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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
State Zip
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.
%` c .!"
Type oy print name Title or Authori
Signature
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him.
Witness my hand and notarial seal, this
CA��°'
_ IOLPy S
o
Date
a Notary Public of the County of
Ili/ 1/, Z), - /4 1, appeared
duly sworn acknowledged that the above form was
day of
QG� 20 j
Notary
My c mission expires`