NCC233525_FRO Submitted_20231129

TRANSMITTAL
.. �
:. - -- : Tie IRES &
�: : ' ;.;;; BRAKES
At DISCOUNT Prices
May 15, 2023
VIA UPS - OVERNIGHT DELIVERY
Mavis Tire Supply, LLC
Rachael Dickinson
Pre-Construction Project Manager,
Real Estate
200 Summit Lake Drive, Suite 350
Valhalla, NY 10595
Office: [phone] Ext.5038
[e-mail]
Attn:
Andy Mueller
BL Companies
3420 Toringdon Way, Suite 210
Charlotte, NC 28277
Re:
Mavis Store # 2096 Louisburg
Included in Transmittal:
1 copy of executed and notarized Financial Responsibility/Ownership Form
Confidentiality Note: This document, and any attachment to it, contains confidential information intended only for the use of the
designated recipients, which information may also be privileged. If the reader of this document is not the intended recipient, the
document has been received in error and any use, review, dissemination, distribution, disclosure or copying of this message is
strictly prohibited. If you have received this document in error, please notify the sender and immediately destroy this document.

Check if this project is ARPA-funded Li
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.
Mavis Tire #2096
1 . Project Name
*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 Franklin Louisburg
City or Township
Highway/Street Highway 56
Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 08-01 -2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed: $ 1 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 E Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rachael Dickinson E-mail Address [e-mail]
Phone: Office # (914) 984-2500 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jeffrey's Rentals, LLC
Name Phone: Office # Mobile #
9309 Hometown Dr. 9309 Hometown Dr.
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Page No. 748
10. Deed Book No. 1557 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 parfy(ies).
Mavis Southeast, LLC
asuggs©mavis.com
Company Name E-mail Address
358 Saw Mill River Road Sektu1/40 inok 1i
Current Mailing Address Current Street Address
Millwood, NY 10546
C.S i A\4
City State Zip City M
ate Zip
Phone: Office # (914) 984-2500 Mobile # N — CiOD — $ci
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:
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:
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.
S C c„; e Pe vac 1 - �„� 44--; r-
Type or print named - Title or Authority
Signatu e Date \ 1
I, , t.t.J I U . , a Notary Public of the County of 3ftr{ec f-cc
t �
State of Noltl r Cerrglina, hereby certify that /TnkhOl (/), '3a-G �j appeared personally
before me this day and being duly sworn acknowledged&hat the above form was executed by him/her.
r.
Witness my hand and notarial seal, this Iv day of /na , , 20 2- 3
J z SLJLLA
Notary
My commission expires ! 2'Z 3 20 2-
DANINE M SKELLY
Notary Public, State of New York
NO. 01SK6401980
Qualified in Westchester County
Commission Expires 12/23/2023

Continued from Items 9 & 10 in Pail 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.