NCC231216_FRO Submitted_20230505

(ATTACHMENT A)
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 Environment and Natural Resources. (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.
1. Project Name: Dollar General
2. Location of land-disturbing activity: Onslow County City or Township: City of Jacksonville
Highway/Street: Rocky Run Road Latitude: 34°43'48" Longitude: 77° 19'10"
3. Approximate date land-disturbing activity will commence: December 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.00
6. Amount of fee enclosed: $ 575.00
The application fee of$225.00 for the first acre plus $125 for every additional acre (rounded up to the
next acre) is assessed without a ceiling amount. (Example: 6.4-acre application fee is $975).
7. Has an erosion and sediment control plan been filed? Yes ❑ No ❑ Enclosed ✓❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name: George Venters E-mail Address: [e-mail]
Telephone #: [phone] Cell #: 919-604-5480 Fax #: [phone]
9 3825 Barrett Drive Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
10. Deed Book: 1133 Page Number: 513 (Provide a copy of the most current deed)
Part B.
1. Person(s) or firm(s)who are financially responsible for the land-disturbing activity
(Provide a comprehensive list of all responsible parties on an attached sheet):
Glandon Forest Equity, LLC [e-mail]
Name E-mail Address
3825 Barrett Drive Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Telephone #: [phone] Cell #: 919-524-2020 Fax #: [phone]

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone #: Cell #: Fax #:
(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:
Name t-mail Address
-J`2D25 TpcurOck. Drive. Sua, 9. 100
Current Mailing Address Current Street Address
iOk 27609
4City State Zip City State Zip
Telephone #: [phone] Cell #: 919-524-2020 Fax #: [phone]
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.
George Barnes Member/manager
Type or prin a Title or Auth rity
'2O \
Signature Date
I, ugh Umtill Cat fJoait5 ,a Notary Public of the County of \ C 1-Nk
State of North Carolina, hereby certify that c,torq CJoar c\if appeared personally
before me this day and being duly sworn acknowiedgeMthat the above form was executed by him.
Witness my hand and notarial seal, this �O day of 4t-e%t:L.Ly ,20 Z.'L
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