NCC233302_FRO Submitted_20231113

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REFUEL OPERATING COMPANY LLC 2045 £
1 LICENSE AND PERMITS £
4105 Faber Place Dr Ste 300
67-181/532 +
North Charleston,SC 29405
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DATE /I. J. Zo23
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After printing this label
CONSIGNEE COPY-PLEASE PLACE IN FRONT OF POUCH
1.Fold the printed page along the horizontal line.
2.Place label in shipping pouch and affix it to your shipment.
Use of this system constitutes your agreement to the service conditions in the current FedEx Service Guide,available on
fedex.com.FedEx will not be responsible for any claim in excess of$100 per package,whether the result of loss,damage,
delay,non-delivery,misdelivery,or misinformation,unless you declare a higher value,pay an additional charge,document
your actual loss and file a timely claim.Limitations found in the current FedEx Service Guide apply.Your right to recover from
FedEx for any loss,including intrinsic value of the package,loss of sales,income interest,profit,attorney's fees,costs,and
other forms of damage whether direct,incidental,consequential,or special is limited to the greater of$100 or the authorized
declared value.Recovery cannot exceed actual documented loss.Maximum for items of extraordinary value is$1,000,e.g.
jewelry,precious metals,negotiable instruments and other items listed in our Service Guide.Written claims must be filed
within strict time limits,see current FedEx Service Guide.

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 NCGO1 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 Name Refuel Market - Riverlights
'If 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: County New Hanover City or Township Wilmington
Highway/Street Arnold Dr Latltude(decimal degrees)34.132 Longltude(decimal degrees) -77.919
3. Approximate date land-disturbing activity will commence: 12/1/23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.81
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 0 Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ryan Robinson E-mail Address [e-mail]
Phone: Office# 865-337-9372 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Refuel Operating Company, LLC 843.800.0771 540.533.5093
Name Phone: Office# Mobile#
4105 Faber Place Dr., Suite 300 Same
Current Mailing Address Current Street Address
North Charleston, SC 29405
City State Zip City State Zip
10. Deed Book No. RB 6646 Page No. PG 2726-2737 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).
Refuel Operating Company, LLC [e-mail]
Company Name E-mail Address
4105 Faber Place Dr., Suite 300
Current Mailing Address Current Street Address
North Charleston, SC 29405
City State Zip City State Zip
Phone: Office# 843.800.0771 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 [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Ave Ste 550
Current Mailing Address Current Street Address
Raleigh, NC 27608
City State Zip City State Zip
Phone: Office# 843.800.0771 Mobile#
lan Bowers, VP of Legal
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.
Travis Smith Chief Development Officer
Type or ar art n Title or Authority
11/1/23
Signature Date
Elizabeth Plasters , a Notary Public of the County of Charleston
State of North Carolina, hereby certify that Travis Smith 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 day of No embe 20 23
My commission expires /•/O
Notary Public- ta`te of South Carotirr:
ELIZZBETH PLASTERS
My eommission EXf)Ires -
J•enuary 10,2032

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:
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 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.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#