NCC231310_FRO Submitted_20230505

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 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 and/
or fax information unavailable, place N/A in the blank.)
P1.art AProject Name Harris Teeter Fuel #129 - Sun Valley
2. Location of land-disturbing activity: County Union City or Township Indian Trail
Highway/Street Old Monroe Rd Latitude 35.049037 Longitude-80.648832
3. Approximate date land-disturbing activity will commence:October 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.74
6. Amount of fee enclosed: $260 . 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
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kevin Lentz E-mail Address [e-mail]
Telephone [phone] Cell # Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mustang Park, LLC
Name Telephone Fax Number
1012 Shippon Lane 1012 Shippon Lane
Current Mailing Address Current Street Address
Waxhaw, NC 28173 Waxhaw, NC 28173
City State Zip City State Zip
10. Deed Book No. 07773 Page No.011 O 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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Harris Teeter Properties, LLC [e-mail]
Name E-mail Address
701 Crestdale Road 701 Crestdale Road
Current Mailing Address Current Street Address
Matthew, NC 28105 Matthew, NC 28105
City State Zip City State Zip
Telephone [phone] Fax Number

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:
Jacob Phares [e-mail]
Name of Registered Agent E-mail Address
701 Crestdale Road 701 Crestdale Road
Current Mailing Address Current Street Address
Matthews, NC 28105 Matthews, NC 28105
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.
Jacob Phare
7Vice President
Type or pri' - Title or Authority
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S Date
rY11 l ,1 S�1 1 (lit 5 , a Notary Public of the County of MeG kle,I')hU rig
State of North Carolina, hereby certify that 0aCO b P h a re,s appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this o2 Li- day of NAgU ,
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