NCC223639_FRO Submitted_20221027

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1.
Proiect Name New Dixie Commercial Park
2. Location of land -disturbing activity: Counly_Halifax City or Township_ Weldon
1606 Julian R. Allsbrook Hwy. 36.431724-77,626737
Highway/Street Latitude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Mid August (8-1 5-22)
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.0
6. Amount of fee enclosed: $ 700 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott Aman E-mail Address [e-mail]
Phone: Office # 252-537-4118 ext.221 Mobile # [phone]
9, Landowner(s) of Record (attach accompanied page to list additional owners):
New Dixie Real Estate Co., LLC 252-537-4118 ext.221
Name Phone: Office #
P.O. Box 779
1501 Marshall Street
252-578-0175
Mobile #
Current Mailing Address Current Street Address
Roanoke Rapids, NC 27870 Roanoke Rapids, NC 27870
City
State Zip
10. Deed Book No. PB--2021
Page No.
City
143
State
Zip
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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
New Dixie Real Estate Co., LLC
Company Name
P.O. Box 779
Current Mailing Address
Roanoke Rapids, NC 27870
[e-mail]
E-mail Address
1501 Marshall Street
Current Street Address
Roanoke Rapids, NC 27870
City State Zip City State Zip
Phone: Office # 252-537-4118 ext.221 Mobile # [phone]
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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
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.
Scott Aman Owner, President
Type or print name Title or Authority
6
Signature Date
� 1
State of North Carolina, hereby certify that -S CO-ft J k CLn appeared personally
before me this day and being duly sworn acknoiedged that the above form was executed by him/her.
r
Witness my hand and notarial seal, this LIEday of '1 , 20-oR_
Notavy
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My commission expires
I

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:
New Dixie Oil Corporation 252-537-4118 ext.221 252-578-0175
Name Phone: Office # Mobile #
P.O. Box 779 1501 Marshall Street
Current Mailing Address Current Street Address
Roanoke Rapids, NC 27870 Roanoke Rapids, NC 27870
City State Zip City State Zip
Deed Book No.-- 558 Page No._380 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
Phone: Office #
Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. _ Page No. Provide a copy of the most current deed.
Landowner 4 of Record.
Name
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. _ Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B 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 State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address
City
Phone: Office #
Current Street Address
State Zip City State
Mobile #
Zip
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #