NCC232287_FRO Submitted_20230801

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate a 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, Health
and Natural Resources. (Please type or print and, if question is not applicable, place N/A in the
blank).
Part A. General Plan Level II For WaWa - #5902 Benvenue Road & Jeffreys Road
1. Project Name Rocky Mount, North Carolina 27804
2. Location of land-disturbing activity: County Nash County
City or Township Rocky Mount , and Highway/Street Benvenue Road
3. Approximate date that land-disturbing activity will be commenced:
4. Purpose of development(residential, commercial, industrial, etc.) Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 2.54 Acres
6. Amount of fee enclosed $ 150
7. Has an erosion and sedimentation plan been filed? Yes No
Enclosed X
8. Person to contact should sediment control issues arise during land-disturbing activity.
Name Jeffrey Lewin Telephone [phone]
9. Landowner(s)of Record(Use blank page to list additional owners):
Rocky Mount ARD CGP LLC
Name(s) 361 Summit Blvd, Suite 110
3611 Summit Blvd, Suite 110
Current Mailing Address Current Street Address
Birmingham, AL 35243 Birmingham, AL 35243
City State Zip City State Zip
EI 10. Recorded in Deed Book No. 3189 Page No. 642
Part B.
1. Person(s)or firm(s)who are financially responsible for this land-disturbing
activity (Use a blank sheet to list additional persons or firms):
Rocky Mount ARD CGP LLC
Name(s)
361 Summit Blvd, Suite 110
361 Summit Blvd, Suite 110
Current Mailing Address Current Street Address
Birmingham, AL 35243 Birmingham, AL 35243
City State Zip City State Zip
602-908-1424 602-908-1424
Telephone Telephone

2. (a) If the Financially Responsible Party is not a resident of North Carolina give name and
street address of a North Carolina Agent.
Name
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Telephone
(b)If the Financially Responsible Party is a Partnership or other person engaging
business under and 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
Registered Agent.
National Registered Agent
Name of Registered Agent
160 Mine Lake Ct, #200 160 Mine Lake Ct, #200
Current Mailing Address Current Street Address
Raleigh, NC 27615-6417 Raleigh, NC 27615-6417
City State Zip City State Zip
919-821-7762 919-821-7762
Telephone Telephone
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 b y the financially responsible
person if an individual or his attorney-in-fact or if not an individual,an officer,director,
partner or registered agent with 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.
Danielle E.Yance Authorized Agent
T e or pri e Title or Authority
November 1,2022
ature Date
I, Elizabeth Pilgrim ,A Notary Public of the County of Jefferson,
State of Alabama,hereby certify that Danielle E.Yance
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 1st day of November ,2022
Seal fj4
1
Notar , liza eth Pilgrim
ELIZABETH PILGRIM
NOTARY PUBLIC,ALABAMA STATE AT LARGE My commission expires
MY COMMISSION EXPIRES NOV.12,2024