NCC233468_FRO Submitted_20231122

Check if this project is ARPA-funded ❑
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 Name Sheetz - Warsaw
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Duplin City or Township Warsaw -
NC HWY 24 (College St.) 34.993025 -78.127253
Highway/Street Latitude(declmal degrees) Longitude(decmai degrees)
3. Approximate date land-disturbing activity will commence:Summer 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):8.7 ac
6. Amount of fee enclosed: $900.00 . 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 ❑ Enclosed x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Downs E-mail Address [e-mail]
Phone: Office# 919-264-8593 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Quality Oil Company, LLC 336-722-3441
Name Phone: Office# Mobile#
1540 Silas Creek Parkway 1540 Silas Creek Parkway
Current Mailing Address Current Street Address
Winston-Salem, NC 27127 Winston-Salem, NC 27127
City State Zip City State Zip
10. Deed Book No. 1 200 Page No.0573 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).
Sheetz, Inc. [e-mail]
Company 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
Mobile# [phone]
Phone: Office# n/a
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:
Steven Augustine [e-mail]
Name of Registered Agent 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
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:
Corporate Service Company n/a
Name of Registered Agent E-mail Address
2626 Glenwood Ave., Suite 550 2626 Glenwood Ave., Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Phone: Office# 1-800-927-9800 Mobile# N/A
ID #7348024
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.
Steven Augustine Assistant Secretary
Type or print na e Title or Authority
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— 13-a3
Signat Date
I, A 11 5�; r`rl��r� r+e }- , a Notary Public of the County of Blat r
PtnASAA( rnc�
State of Nertlt uaryulirta, hereby certify that � Uen C. i n 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 3 day of Apr, , 20,
Commonwealth of Pennsylvania-Notary Seal OD U
Alissa Morgret,Notary Public Notary
Blair County
My commissiarilexpires October 23,2024
Commission number 1384847 My commission expires /D - d 3- a
Member,Pennsylvania Association of Notaries

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:
EC Thompson & JG Ludlow
Name Phone: Office# Mobile#
404 North Pine Street 404 North Pine Street
Current Mailing Address Current Street Address
Warsaw, NC 28398 Warsaw, NC 28398
City State Zip City State Zip
Deed Book No. 996 Page No.231 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#

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