NCC232803_FRO Submitted_20230918

�g87 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of °`Pg SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
Couthern ines 140 Memorial Park Court
The Mid So Nortuth RehCarosortlina Southern Pines, North Carolina 28387
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Interneiionlly Recognized for Program Escellence Telephone: [phone]—Fax: [phone]
No person may initiate any land-disturbing activity greater than 30,000 sq. ft. (including lots or tracts of land that are
a part of a Common Plan of Development that the total disturbance will exceed 30,000 sq.ft.) as covered by the
Town's Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been
completed and approved by the Town of Southern Pines. (Please type or print and, if the question is not applicable
or information unavailable, place N/A in the blank.)
Part A.
1. Project Name: Sheetz Southern Pines
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address 1930 N Poplar Street
3. Latitude: 35.1586003 Longitude: -79.4119253 PIN: 857115720651
4. Percent Impervious: 61.6% (1.32 acres)
5. Approximate date that land-disturbing activity will commence: May 2023
6. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.41 Acres
8. Amount of fee enclosed: $ 600.00
The application fee is $300.00 for the first acre plus$150.00 for each additional acre, or part thereof.
The revised plan review fee is $50 for each submittal after the 2nd review.
Any substantial revision to a previously approved,active plan is $50 per acre, or part thereof.
No Fee for Minor Construction Activities less than 30,000 sq. ft. of disturbance,
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tom Anastasi E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Derby Investment Company, LLC
Name Telephone Fax#
1930 N Poplar Street, Suite 18
Current Mailing Address Current Street Address
Southern Pines NC 28315
City State Zip City State Zip
11. Deed Book No. 3041 Page No. 186 (Provide a copy of the most current deed).

Part B.
1. Person(s) or firm(s) who is financially responsible for the land-disturbing activity
(Provide a comprehensive list of all responsible parties on an attached sheet):
Sheetz, Inc. - Steve Augustine [e-mail]
Name E-mail Address
5700 Sixth Avenue 5700 Sixth Avenue
Current Mailing Address Current Street Address
Altoona PA 16602 Altoona PA 16602
City State Zip City State Zip
Telephone [phone] Fax#
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:
Corporation Service Company [e-mail]
Name of Registered NC 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
Telephone [phone] Fax# [phone]
(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:
Tim O'Brien [e-mail]
Name of NC 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
Telephone [phone] 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.
S+t veVI P Us1vi VP o� .s- Ye. (DeU�lopwtevt.--
Type or print na Title or Authority
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Signs u Z Date
I, f-A,\ ({'�v re� , a Notary Public of the County of 3 tat r
State of N•t S +ra reby certify that v c..n P. A c, Shr�e
appeared personally before me this day and being duly sworn ackdlowledged that the above form
was executed by him. `--
Witness my hand and notarial seal, this Q day of J LL 1 to , 20 3
Commonwealth of Pennsylvania-Notary Seal CLUL.a.0:(-6 fn0
AV-1—
_ Alissa Morgret,Notary Public
Blair County Notary
Seal My commission expires October 23,2024
Cammiselon number 1384847 My commission expires ) () -ca(3 - d 4
Member,Penneylvenla Aeeoolallon
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9,2020