NCC230642_FRO Submitted_20230310

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 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.
2.
3.
4.
5.
6.
7
Project Name Family Dollar
Location of land -disturbing activity: County Johnston City or Township Princeton
Dr. Donnie H. Jones Jr. Blvd. 35.470-78.164
Highway/Street Latltude(decimaldegrees) LOngltude(decimaldegrees)
Approximate date land -disturbing activity will commence: Winter 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.2
Amount of fee enclosed: $ 200.00 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Barnes Boykin Email Address [e-mail]
Phone: Office # 252-230-0632 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
James & Teresa Baker 252-230-0632 N/A
Name Phone: Office # Mobile #
566 Princeton Road Same
Current Mailing Address Current Street Address
Princeton NC 27569 Same
City State
10. Deed Book No. 5859
Zip City
Page No. 543
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).
Cedar Run Capital, LLC [e-mail]
Company Name E-mail Address
2405 F Nash St. N. Same
Current Mailing Address Current Street Address
Wilson NC 27896 Same
City State Zip City State
Phone: Office # 252-230-0632 Mobile # [phone]
Z_1V
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 Parry is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
NIA
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.
NIA
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.
Barnes Boykin Member/Manager
Type or print name Title or Authority
Signature Date
a Notary Public of the County of % Sow,/_
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged thatt a above form was executed by him/her.
Witness my hand and notarial seal, this _ day of , 20 2 z
Steven Lee Ohverio
SOOTARY PUBLIC
Wilson County, V
I My Commission Expires 1Z4b =269 3
Notary
My commission expires 1/—/S %d

Continued from Items 9 & 90 in Part A of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
N/A
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
N/A
Name
Current Mailing Address
City State
Deed Book No.
Landowner 4 of Record:
N/A
Name
Current Mailing Address
City State
Deed Book No.
Landowner 5 of Record:
N/A
Name
Current Mailing Address
City State
Deed Book No_
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No_ Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial ResponsibilitylOwnership Form for multiple panties.
Attach copies of this page as needed to list all financially responsible parties.
N/A
Company 2 Name
Current Mailing Address
City
Phone: Office #
N/A
Company 3 Name
Current Mailing Address
C ity
Phone: Office #
N/A
Company 4 Name
Current Mailing Address
City
Phone: Office #
N/A
Company 5 Name
Current Mailing Address
City
Phone: Office #
State
E-mail Address
Current Street Address
Zip City
Mobile #
E-mail Address
Current Street Address
State
Zip
State Zip City State Zip
Mobile #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
State
E-mail Address
Current Street Address
Zip City State
Mobile #
Zip