NCC231091_FRO Submitted_20230419

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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.
Project Name Bladenboro Dollar General
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water infrastructure (DWI).
2. Location of land -disturbing activity: County Bladen City or Township Elizabethtown 1
Twisted Hickory Road 34.573886-7B.669781
Highway/Street Latliude(dedmaltlegrees) LonglYude(decimaidegrees)
3. Approximate date land -disturbing activity will commence: June 1 , 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.6
6. Amount of fee enclosed: $ 300 . 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.
7. 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 John Parker E-mail Addresspermits 9 rhetson.com
Phone: Officeit 910-944-0881 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Franklin C White 919-876-0266
Name Phone: Office # Mobile #
6605 Johnsdale Road
Current Mailing Address
Raleigh NC 27615
Current Street Address
City State Zip City
10. Deed Book No. 233 Page No. 661
State
E
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).
Rhetson Companies, Inc
Company Name
2075 Juniper Lake Road
Current Mailing Address
West End NC 27376
jennifer@ rhetson.com
E-mail Address
Current Street Address
City State Zip City
Phone: Office # 910-944-0881 Mobile #
State
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
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:
Name of Registered Agent E-mail Address
Current Mailing Address
Current Street
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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
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.
S . IFYYr t n'o ,r_, E V i? a-� 17,:ef"tmS
Type or print nam Title or Authority
Si atu're Date
I, N 1 C6lQ `� - O, C , a Notary Public of the County of of A %Z 1
State of North Carolina, hereby certify that J Q, L-e-) S• Ef) Ci l JODSCi, appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal,
D. O
"o�E,... Cccsn
,,,,OSA1?1, ;O.
Seal ;
2p %G % U
y1 •. U61-
this H day of � C V t 20 Qll
N ary
My commission expires i ` bri�+

Continued from Items 9 & 10 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
Current Mailing Address
City State Zip
Deed Book No. Page No._
Phone: Office # Mobile #
Current Street Address
State Zip
Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book
Landowner 4 of Record:
Current Street
State Zip City State Zip
Page No. Provide a copy of the most current deed.
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 5 of Record:
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.

Continued from Item 1 in Part 8 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City Slate Zip
Phone: Office # Mobile #
Company 4 Name
E-mail Address
Current Mailing Address Current Street Address
City State
Phone: Office #
City State Zip
Mobile It
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Officeit Mobile #