NCC223987_FRO Submitted_20221206

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 Environment and Natural Resources. (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 WENDYS
2. Location of land -disturbing activity: County ONLSLOW City or Township RICHLANDS
Highway/Street NC HWY 258 Latitude 3 4 d5 3' 2 6 "N Longitude 7 7 d3 2' 5 3 "W
3. Approximate date land -disturbing activity will commence: 8-15-2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2 . 2 9 a. c .
6. Amount of fee enclosed: $ 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 x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Victor Kozma E-mail Address vkozma@classicburgers . com
Telephone 7 0 4— 9 4 0 —15 0 9 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
24 East Development, LLC
Name
Telephone Fax Number
PO Box 295
Current Mailing Address
Current Street Address
Richlands NC 28574
City State Zip
City State Zip
10. Deed Book No. 4880 Page No.
357 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on
an attached sheet):
Carolina Restaurant Group Inc
[e-mail]
Name
E-mail Address
8040 Arrowridge Blvd Ste 100
8040 Arrowridge Blvd Ste 100
Current Mailing Address
Current Street Address
Charlotte NC 28273
Charlotte NC 28273
City State Zip
City State Zip
Telephone 7 0 4— 9 4 0 —15 0 9
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
C ity
Telephone
E-mail Address
Current Street Address
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:
Name of Registered Agent
Current Mailing Address
•r a wl G 2--7-76
City
Telephone
�J Goa u.d... Q) C L-N 8 s
E-mail Address
Current Street Address
State 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.
Type or print name
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Signature
- ----------- ----------- ------------------------------- ------ -
Title or Authority
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Date
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I, A, a Notary Public of the County of
State of North Carolina, hereby certify that VV1 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 day of -
y —R—isF�er Canady
• NOTARY PUBLIC
Gaston County
Notary � My Commission Expires December 6, 2025
Seal
My commission expires MY M&O WE rk21(01.,,1t,�