NCC230243_FRO Submitted_20230127

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Duality. 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 N/A in the blank.)
Part A. Circle K - Elk Rd & Legion Rd
1. Project Name 9
2. Location of land -disturbing activity: County Cumberland
Highway/Street Elk Rd & Legion Rd Latitude 34.983520
3
City or Township Hope Mills
Longitude-78•930530
Approximate date land -disturbing activity will commence: 8/1 /2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): +j_ 2.58 AC
6. Amount of fee enclosed: $ 195.00 . 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
S. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Peter Doster E-mail Address [e-mail]
Telephone [phone]
cell # [phone]
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CE PROPERTIES LLC
Name
PO BOX 715
Telephone
Current Mailing Address Current Street Address
Hope Mills NC 28348
City
10. Deed Book
State
9703-0667
Zip City
Page No. 0667
Fax Number
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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Circle K Stores Inc. [e-mail]
Name E-mail Address
1100 Sitrus Court, Ste. 100
Current Mailing Address
Raleigh, NC 27606
City State
Telephone [phone]
Current Street Address
Zip City
Fax Number
State
Zip

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:
Meredith W. Rice [e-mail]
Name of Registered Agent E-mail Address
1100 Sitrus Court, Ste 100
Current Mailing Address Current Street Address
Raleigh, NC 27606
City State Zip City State Zip
Telephone [phone] 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.
Meredith W. Rice, Jr
Type or print name
Signature
Vice President, Operations
Title or Authority
Date
I, fC�Da ! Ii �: r�1 a Notary Public of the County of JzAnsffr'_
State of North Carolina, hereby certify that 1�w),_eI&I appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my nand and notarial seal, this day of ' , 2g
ROBIN F. ALFOR❑
Notary Public, North Carolina
Johnston County
Nota
My:3981mission Expires
April 23, 2023
My commission expires��3

Bowman
July 2, 2021
NCDEQ
Fayetteville Regional Office
225 Green Street, Suite 714,
Fayetteville, NC 28301-5095
Re: Circle K — Elk Rd & Legion Rd
Financial Responsibility Form
Additional Owner Information
To NCDEQ Fayetteville Regional ❑ffice:
Please find below additional owner information for Financial Responsibility Farm for the above
referenced project. Please let us know if additional information is required.
Landowner of Record 2: RIDDLE, DOROTHY M;RIDDLE, EDWARD R
Current Mailing Address: 4031 ELK RD, HOPE MILLS, NC 28348
Deed Book No: 3215
Page: 014
Landowner of Record 3: RIDDLE, DOROTHY M;RIDDLE, EDWARD R
Current Mailing Address: 4031 ELK RD, HOPE MILLS, NC 28348
Deed Book No: 3626
Page: 0617
Sincerely,
Circle K Stores Inc,
Meredith Rice
Vice President, Operations
4350 Main St. Suite 219 Harrisburg, NC 28075
704.412.7474
bowman.com