NCC233184_FRO Submitted_20231025

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 Dollar General - Pilot Mountain Store #30009
2. Location of land-disturbing activity: County Surry City or Township Pilot Mountain
Highway/Street Mary Moore Drive Latitude(declmal degrees)36.3843 Longitude(declmal degrees)-80.4546
3. Approximate date land-disturbing activity will commence: November 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.92 acres
6. Amount of fee enclosed: $ 200 . 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 C7 Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Joe Strickland E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Pilot Holistic Home & Garden, LLC 336-444-0125
Name Phone: Office# Mobile#
625 E. 52 Bypass 625 E. 52 Bypass
Current Mailing Address Current Street Address
Pilot Mountain, NC 27041 Pilot Mountain, NC 27041
City State Zip City State Zip
10. Deed Book No. 1847 Page No.862 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).
Teramore Development, LLC [e-mail]
Company Name E-mail Address
214 Klumac Road Suite 101 214 Klumac Road Suite 101
Current Mailing Address Current Street Address
Salisbury NC 28144 Salisbury NC 28144
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:
Joe Strickland [e-mail]
Name of Registered Agent E-mail Address
214 Klumac Road Suite 101 214 Klumac Road Suite 101
Current Mailing Address Current Street Address
Salisbury, NC 28144 Salisbury, NC 28144
City State Zip City State Zip
Phone: Office# Mobile# [phone]
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.
Joe St( and Agent
Type rint name Title or Authority
Q
nature Date
I, 6.41Nt'21' 24 L , a Notary Public of the County of f u W 'Ai
State of North Carolina, hereby certify that -TOE S i ✓t is tC t_A-N. appeared personally
before me this day and being duly sworn acknowledged that the above forrrt was executed by him/her.
Witness my hand and notarial seal, this 2 i day of 4 Li S i , 20 2_3
DANIEL R.ALMAZAN
NOTARY PUBLIC Notary
Rowan County _
North Carolina My commission expires J"a Z 8- 2 4 2 7
My Commission Expires June 28,2027

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:
G&B Oil Co Inc. 336-835-3607
Name Phone: Office# Mobile#
227 N Elkin Drive 227 N Elkin Drive
Current Mailing Address Current Street Address
Elkin, NC 28621 Elkin, NC 28621
City State Zip City State Zip
Deed Book No. 1 659 Page No. 181 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.