NCC232159_FRO Submitted_20230720

dilU all dUL:eplidUlU erosion ana eUntroi pian nave 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 McDonald's
*/f this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Stokes City or Township Walnut Cove
Highway/Street N. Main Street 36.312200 -80.13981
Latitude(decimal degrees) Longitudeoecimai degrees)
3. Approximate date land-disturbing activity will commence: June 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 '33
6. Amount of fee enclosed: $ 200•00 . 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 m No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian A. Redder E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
EVRTAN INC
Name Phone: Office # Mobile #
632 S. Main Street 632 S. Main Street
Current Mailing Address Current Street Address
Walnut Cove NC 27502 Walnut Cove NC 27502
City State Zip City State Zip
Page No. 628
10. Deed Book No. 674 Provide a copy of the most current deed.

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).
McDonald's USA, LLC [e-mail]
Company Name E-mail Address
110 N. Carpenter Street 110 N . Carpenter Street
Current Mailing Address Current Street Address
Chicago, IL 60607 Chicago, IL 60607
City State Zip City State Zip
Phone: Office # Mobile # [phone]
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
Name of Registered Agent E-mail Address
2626 Glenwood Avenue, Suite 550 2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
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:
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.
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.
cz..1 Pt ki A. REDe(Z Aga Go oTR Acre aN M?N h�E R
Type or rint name Title or Authority
W (oi 20 Z 3
Sig ature Date
I, C/cu'vllklt CXitrnpbfJI , a Notary Public of the County of Join on _ coarl,
State of North Carolina, hereby certify that Vict.n '. Redd Gr 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 (.0 day of , 20 a3
G AM Pei CanGin.t. Ce2A/Obeit I
C Notary
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cr. : p'a� My commission expires 3- "( '02 S
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