NCC230122_FRO Submitted_20230117

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 NIA in the blank.)
Part A.
1.
2.
3.
4.
5.
Project Name Sheetz Durham Ellis
Location of land -disturbing activity: County Durham City or Township Durham
Highway/StreetYurluS Rd
Latitude(decim85.9401al degrees) Longliude(decimal degrees) -78.8560
Approximate date land -disturbing activity will commence: 1 /30/23
Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.89
6. Amount of fee enclosed $2,200 . 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, afterwhich 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 ❑ No 0
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity.
Name Wes Hall E-mail Address WWhalliC- sheetz.com
Phone: office # 919-896-2019 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ellis Rd Durham NC LLC
Name Phone: Office # Mobile #
901 Wabash Ave Suite 300
Current Mailing Address Current Street Address
Terre Haute, IN 47807
City State Zip City State Zip
10. Deed Book No, 9444 Page No. 161 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 fs) of the owner(s) may be listed as the financially responsible party(ies).
Sheetz, Inc.
Company Name
351 Sheetz Way
Current Mailing Address
Claysburg PA 16625
City State Zip
Phone: Office #
[e-mail]
E-mail Address
351 Sheetz Way
Current Street Address
Claysburg PA 16625
City State Zip
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:
Corporation Service Company
Name of Registered Agent E-mail Address
2626 Glenwood Ave, Suite 550 2626 Glenwood Ave, Suite 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Phone: Office # 866-403-5272 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
(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:
Kimley-Horn & Associates, Inc.
Engineering firm or other consultant
Chris Bostic
Individual contact person (type or print)
chris.bosticga kimley-horn.com
E-mail Address
919-653-2927 919-623-0414
Phone: Office # Mobile #
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.
Steven P. Augustine
Type or print na e
i z
Signatu
VP of Store Development
Title or Authority
�4 —1__2`
Date
I, r 4- , a Notary Public of the County of � CQI I'
State of North Carolina, hereby certify that ft? e`en tom,A%Auu, rat' appeared personally
before me this day and being duly sworn acknowledged that the ab a form was executed by him/her.
Witness my hand and notarial seal, this
Commonwealth of Pennsylvania - Notary Seal
Alissa Margret, Notary Public
SlairCounty
Mycommisg�q,pxplres October 23, 2024
comrrrilssion number 1384847
Member, Pennsylvania Association of Notaries
4 �. i day of J , 24 0 3
CU QAQA 9+
Notary
My commission expires - 03 _ 3`4

Continued from Items 9 & 90 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 #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No, Page No.
Landowner 3 of Record:
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip City
Deed Book No. Page No.
State Zip
Provide a copy of the most current deed.

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