NCC233234_FRO Submitted_20231117

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 Dunn, NC - Petco
2. Location of land-disturbing activity: County Harnett City or Township Dunn
US HWY 421-W.Cumberland Street 35.322783 78.640256
Highway/Street Latitude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 1 0'1 0'22
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
1.677
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❑x Enclosed ❑x No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Blake Pryor E-mail Address [e-mail]
Phone: Office# 512.819.4881 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sorrell Jackson, LLC 252.342.4064 N/A
Name Phone: Office# Mobile#
1507 Arendell Street 1507 Arendell Street
Current Mailing Address Current Street Address
Morehead City, NC 28557 Morehead City, NC 28557
City State Zip City State Zip
10. Deed Book No.2456 Page No.75 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).
PC-Dunn, NC-1 -UT, LLC [e-mail]
Company Name E-mail Address
4747 Williams Drive 4747 Williams Drive
Current Mailing Address Current Street Address
Georgetown, TX 78633 Georgetown, TX 78633
City State Zip City State Zip
Phone: Office# 512.819.4767 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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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:
Cogency Global Inc. [e-mail]
Name of Registered Agent E-mail Address
212 South Tryon Street Ste 1000 212 South Tryon Street Ste 1000
Current Mailing Address Current Street Address
Charlotte, NC 28281-0001 Charlotte, NC 28281 -0001
City State Zip City State Zip
Phone: Office# 866.775.0114 Mobile# [phone] - Fax #
N/A Colleen Humes
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.
N/A
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.
Type or print namj' PC-Dunn, NC-1-UT,LLC Title or Authority
By:E,fnbr�elopment Group, Inc.
!/ /« -lw—Zu2Z
Signature / Date
I, Evvvvrd4, i'n.frthiL , a Notary Public of the County of V/i/jIhIGI,vn.1}}i
Gt.S
State of N Toting, hereby certify that 1 I v i irm t't1t Vf 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 (J day of g.„( p too lof.Y , 20 ZZ
(---ecAirl-vvii,t,y-fyi-k-i;r
Notary
.�`` Y►fit EMMA L. MUNIZ
_i4wwi Notary Public,State of Texas My commission expires �p— �-2OZlP
'�.,� ti,,,"r Comm.Expires 06-17-2026
''�►i°itr�° Notary ID 13382013-2

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:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 3 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 4 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 5 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Page No. N/A
Deed Book No. N/A 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.
N/A N/A
Company 2 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 3 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 4 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 5 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
N/A N/A
Phone: Office# Mobile#