NCC231118_FRO Submitted_20230419

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 N/A in the blank.)
Part A.
Project NameQVC Fire Restoration
Location of land -disturbing activity: County Edgecombe City or Township None
Highway/Street
100 QVC Blvd. 359223
Latitude(daG.
mai aa9�eas> Long itude(aecimal degrees)
Approximate date land -disturbing activity will commence: April 1, 2023
-77.6820
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.93
6. Amount of fee enclosed $2,450 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Thomas Stokes E-mail [e-mail]
Phone: Office # N/A Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
RMQ Ventures, LLC
Name Phone: Office # Mobile #
2250 59th St. 4th Floor 2250 59th St. 4th Floor
Current Mailing Address Current Street Address
_Brooklyn, NY 11204 Brroklyn, NY 11204
City State Zip City State Zip
10. Deed Book No. 1774 Page No. 310 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 names) of the owner(s) may be listed as the financially responsible party(ies).
QVC Rocky Mount, Inc.
Company Name
1200 Wilson Dr.
Current Mailing Address
West Chester, PA 19380
[e-mail]
E-mail Address
1200 Wilson Dr.
Current Street Address
West Chester, PA 19380
City State Zip City State Zip
Phone: Office # 717-419-9534 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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Ave., Suite 550 2626 Glenwood Ave.
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Phone: Office # 1-800-927-9801 ext. 62049 Mobile #
Gary Sherman
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:
N/A
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.
N/A
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:
TRC Engineers, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Robert Moser 919-828-3150 984-328-9932
Individual contact person (type or print) 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.
Type or print name
Signature,
Title or Authority
3-lri-Lo23
Date
I, Ha(4G, t-. F a Notary Public of the County of P7(„ re_*nc.c,
State of NertCarolina, hereby certify that C16rl S 6 -r /`io = f- 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, this _Z _day of '" f o, r-c k , 20a-
Notary
Seal My commission expi MARGAREi,�E.IFLON�RR ,','
n .
My Commissi6nExpirbes\5
November 07, 2023

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.
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:
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.
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 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
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
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 #