NCC230160_FRO Submitted_20230120

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. Project Name STS of Fayetteville
2. Location of land -disturbing activity: County Cumberland City or Township_ Fayetteville
Highway/Street Shaw Road Latitude,d,,;ma,tleg,,esy 35.115619 Longitude0ed; a,degrees,—78.928297
3. Approximate date land -disturbing activity will commence: January/ February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 4.67
6, Amount of fee enclosed $500 + $1 250 = $1 750. 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 Von Friesen E-mail Address [e-mail]
Phone: Office # 678-232-0593 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
STS of Fayetteville, LLC. 678-232-0593
Name Phone: Office # Mobile #
271 W. Washington Street Suite 100 271 W. Washington Street Suite 100
Current Mailing Address Current Street Address
Madison GA 30650 Madison GA 30650
City State Zip City State Zip
10. Deed Book No. 11375 Page No. 0615-0618 Provide a copy of the most current deed.

Part 16.
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).
STS of Fayetteville, LLC._ _ [e-mail]
Company Name E-mail Address
271 W. Washington Street, Suite 100 271 W. Washington Street, Suite 100
Current Mailing Address Current Street Address
Madison GA 30650 Madison GA 30650
City State Zip City State Zip
Phone: Office # 678-232-0593 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
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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:
CT Corporation of North Carolina
Name of Registered Agent
160 Mine Lake Court Suite 200
Current Mailing Address
Raleigh NC 27615 _
City State Zip
westteam 1 rc7z,wolterskluwer. com
E-mail Address
160 Mine Lake Court Suite 200
Current Street Address
Raleigh NC 27615
City State Zip
Phone: Office # 919-944-4780 Mobile #
Melissa Vogel
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:
Moorman, Kizer & Reitzel, Inc_
Engineering firm or other consultant
James M. Kizer Jr., PE _
Individual contact person (type or print)
'kizer'[e-mail]
E-mail Address
910-484-5191
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��rovide corrected information should there be any change in the information provided
herein. ,
esen
Type or�prjnt , #rie
Signa
Manager
Title or Authority
Date
3(V\f ke7WJ , a Notary Public of the County of LEA RYA
11
State of Ner �a, hereby certify that V 0A'rl`i •e-St*J appeared personally before
me this day and being duly sworn acknowledged that the above form was executed by him/her.
L
Witness my hand and notarial seal, this day of Gary 20 Z��,-7--
Notary 6// `
My commission expires