NCC231222_FRO Submitted_20230505

I
ROCKY MOUNT
PUBLIC WORKS
WE CENTER OF II ALL
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
City of Rocky Mount. (Please return to [e-mail]).
Part A.
1. Project Name Dollar General
2. Location of land-disturbing activity: County Edqecombe
Address Cokey Road Latitude 35.928803 Longitude -77.789172
3. Approximate date land-disturbing activity will begin: April 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed: 1.56 Acres
6. Amount of fee enclosed: $100.00. The application fee of$50.00 per acre (rounded up to the next acre)
is assessed. (Example:For an 8.3 disturbed acreage project, the fee is$450).
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 George Barnes E-mail Address gbarnes a(�vanquardpg.com
Telephone [phone] Cell#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Rocky Mount
Name Telephone
PO Box 1180
Current Mailing Address Current Street Address
Rocky Mount NC 27801
City State Zip City State Zip
10. Deed Book No. 1500 Page No. 0807 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):
Glendon Forest Equity, LLC gbarnes(a�vanquarpq.com
Name E-mail Address
3825 Barrett Drive Suite 100 3825 Barrett Drive Suite 100
Current Mailing Address Current Street Address

Rocky Mount NC 27801 Rocky Mount ' NC 27801
City State Zip City State Zip
Telephone
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
(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:
George Barnes gbarnes anvanquarpq.com
Name of Registered Agent E-mail Address
3825 Barrett Drive Suite 100 3825 Barrett Drive Suite 100
Current Mailing Address Current Street Address
Rocky Mount NC 27801 Rocky Mount NC 27801
City State Zip City State Zip
Telephone [phone] Fax Number 919-459-2604
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 print Title or Authori y
1213 2-2--
Signature Date
I, Qsh Nt(DU 1)0,aA. s , a Notary Public of the County of t'Ir0 nt.U.: 1
State of North Carolina, hereby certify that et,i.3r9(t... rho.* ru.5 appeared
personally before me this day and being duly swots acknowledged that the above form was
executed by him.
Witness my hand Na ' I seal, this l?D da of DedCtimID..r 20 22
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