NCC233006_FRO Submitted_20231010

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
•
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 NameWendy's - Goldsboro, NC
'1!this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e g, SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI)
2. Location of land-disturbing activity: CountyWayne City or Township Goldsboro
Highway/StreetUS Highway 117 Bypass Latitudeid�Ru+d��esi35,332 Longitude(dedn i .)78.035
3. Approximate date land-disturbing activity will commence:9/1/23
4. Purpose of development(residential,commercial,industrial, institutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1 •1 14 ac.
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 0 Enclosed El No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameJosef Levatich E-mail [e-mail]
Phone: Office# 757-765-0295 Mobile# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
SEA Goldsboro, LLC 919-781-8870
Name Phone: Office# Mobile#
2840 Plaza Place, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27612
City State Zip City State Zip
10. Deed Book No.2890 Page No.843 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.)1f the company is a solo proprietorship or if the landowner(s)is
an lndividual(s),the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Delight Raleigh 1 , LLC [e-mail]
Company Name E-mail Address
P.O. Box 780794 120 East End Ave. Apt 10B
Current Mailing Address Current Street Address
Wichita, KS 67278 New York, NY 11028
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 landowners 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:
Registered Agents [e-mail]
Name of Registered Agent E-mail Address
4030 Wake Forest Road, Ste. 349 4030 Wake Forest Road, Ste. 349
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
City State Zip City State Zip
Phone: Office# 919-400-4138 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.
Richard Krumholz Co-President
Type or print name Title or Authority
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Signature Date
I,Jec-c-1 6 ra .e.td , a Notary Public of the County of
State of NOltreefeltftth hereby certify that V-,t C. rct.k riA-PAA,N.0 I z. appeared personally
before me this day and being duly sworn acknowledgedc1 that the above form was executed by him/her.
Witness my hand and notarial seal,this Lt-day of n 4.4.010'e_r , 20 -23
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