NCC233684_FRO Submitted_20240103

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 - Yadkinville Store #30285
2. Location of land-disturbing activity: County Yadkin City or Township Yadkinville
Highway/Street Old Stage Road Latitude(decimal degrees)36.0865 Longitude(deolmal degrees)-80.6527
3. Approximate date land-disturbing activity will commence:January 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.04 acres
6. Amount of fee enclosed: $300.00 . 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 2 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):
James & Carol Reavis 336-631-5778 _
Name Phone: Office# Mobile#
1228 Peanut Lane 1228 Peanut Lane
Current Mailing Address Current Street Address
Yadkinville, NC 27055 Yadkinville, NC 27055
City State Zip City State Zip
10. Deed Book No. 1105 Page No. 134 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
en Indivldual(s), the name(s)of the owner(s)may be listed as the financially responsible party(les).
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 0.
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 Stick nd Agent
Type or p t name Title or Authority
Date
„ . . ,iN \+tea ms a Notary Public of the County of geolockkr,
State of North Carolina, hereby certify that .-j.0 E 57,,2rc ce; N4 appeared personally
before me this day and being duly sworn acknowledged that the abov m was executed by him/her.
Witness my hand and notarial seal, this 6 _,day of NoW2rt ram , 20'7_3
DANIEL R.ALMAZAN
NOTARY PUBLIC Notary
`Ionian County
North Carolina My commission expires `' vn/ Z o 7
My Commission Expires June 28,2027