NCC241337_FRO Submitted_20240503

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 and/
or fax information unavailable, place N/A in the blank.)
P1. Part .roject Name Dollar Tree - Kernersville, NC
2. Location of land-disturbing activity: CountyForsyth City or TownshipWtnston-Salem
Highway/Street 1591 Glenn Center Drive Latitude 36.0701 Longitude-80.1124
3. Approximate date land-disturbing activity will commence:5/6/24
4. Purpose of development(residential,commercial,industrial,institutional, etc.):Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):1.10 Acres
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 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Scott Bowman E-mail [e-mail]
Telephone[phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
West Point Village Associates, LLC
Name Telephone Fax Number
424 W Mountain St
Current Mailing Address Current Street Address
Kernersville, NC 27284
City state Zip City State Zip
10. Deed Book No. 3244 Page No.' 1010- Provide a copy of the most current deed.
1032 •
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
DT Retail Properties, LLC [e-mail]
Name E-mail Address
2862 Dauphin Street 500 Volvo Parkway
Current Mailing Address Current Street Address
Mobile, AL 36606 Chesapeake, VA 23320
City State Zip City State Zip
Telephone Fax Number
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2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Corporation Service Company
Name E-mail Address
2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation,give name and street address of the Registered Agent:
Coporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Todd Littler Senior Vice President
Type or pri. Title or Authority
41.
_ _ 4/30/24
Sign.' Date
I, G.e.• AAATrI-iEf+.)$ , a Notary Public of the County of 64Esatzsezkiaz VA
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State of Nora noThereby certify that ToD4 L.I-cr LE appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this a74 day of A .1 L. .4-, 20 2
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