NCC231314_FRO Submitted_20230509

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name RaceWay - Winnabow EDO
2. Location of land-disturbing activity: County Brunswick City or Township W i n n abow
George I I HWY 34°07'58.3"N 78°05'43.8"W
Highway/Street Latitude( degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence:January 1st, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.8
6. Amount of fee enclosed: $500 . 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 Caleb Rodgers E-mail Address [e-mail]
Phone: Office# 770-431-7600 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Martha James
Name Phone: Office# Mobile#
48 George II Hwy S.E..E. 48 GEORGE II HWY SE
Current Mailing Address Current Street Address
Winnabow, NC 28479 Winnabow, NC 28479
City State Zip City State Zip
10. Deed Book No.03949 Page No.0299 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).
RaceTrac, Inc. [e-mail]
Company Name E-mail Address
200 Galleria Parkway SE, Suite 900 200 Galleria Parkway SE, Suite 900
Current Mailing Address Current Street Address
Atlanta, GA 30339 Atlanta, GA 30339
City State Zip City State Zip
Phone: Office# 770-431-7600 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:
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)
(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:
Corporate Creations Network Inc. [e-mail]
Name of Registered Agent E-mail Address
15720 Brixham Hill Avenue #300 15720 Brixham Hill Avenue #300
Current Mailing Address Current Street Address
Charlotte, NC 28277 Charlotte, NC 28277
City State Zip City State Zip
Phone: Office# 704-412-3062 Mobile#
Timothy Pratts
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.
Company DBA Name
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.
Karla Ahlert Chief Financial Officer
Type print name Title or Authority
VA 11/22/22
Signature Date
Kathryn Whitaker , a Notary Public of the County of Cobb
State of Georgia , hereby certify that Karla Ahlert 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 22 day of November 2022
4&qt
Seal I
My commission expires I 0 125 I 1:2-
KATHRYN WHITAKER
I Notary Public-State of Georgia
Cobb County
( My Commission Expires Oct 25,2025

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:
Robert James
Name Phone: Office# Mobile#
48 GEORGE II HWY SE 48 GEORGE II HWY SE
Current Mailing Address Current Street Address
Winnabow, NC 28479 WINNABOW, NC 28479
City State Zip City State Zip
Deed Book No.01 736 Page No.0782 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.
Landowner 4 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.
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 I 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#