NCC241643_FRO Submitted_20240530

' 1 City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
14111sIoIhScalPlll Mailing: PO Box 2511,Winston-Salem,NC 27102
Financial Responsibility/Ownership Form
No person may initiate any land-disturbing activity exceeding 20,000 square feet for Single-Family Dwelling construction, 10,000
square feet for any other non-exempt purpose,or part of a larger common plan of development exceeding these thresholds,before this
form and an acceptable Erosion Control Plan have been submitted,reviewed,and approved by the City of Winston-Salem Erosion
Control Division and a Grading/Erosion Control Permit has been issued. Please type or print.Please place"N/A"in the blank space if
not applicable.
Part A
Project Name: WINSTON-SALEM SHEETZ
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 2698 PETERS CREEK PKWY WINSTON-SALEM, NC 27127
Latitude: 36.056625 Longitude: -80.260031
Approximate Date that Land-disturbing Activity will Commence: JULY 1, 2024
Purpose of Grading:
® Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 2.20 Acreage to be Disturbed: 2.05
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: TOM ANASTASI Email: [e-mail]
Office Phone: Mobile Phone: [phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#•6824-72-3211.000 Tax Block#: 3816 Tax Lot PIA
Name: W. REED LEVERTON
Street Address/PO Box: PO BOX 24097
City/State/Zip Code:WINSTON-SALEM, NC 27114
Office Phone: [phone] Mobile Phone: Fax#:
Grading Contractor Information: (if known at time ofsubmitting the Erosion Control Plan for review)
Value of Grading Contract:$ UNKNOWN City of WS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/PO Box:
City/State/Zip Code:

Part B
Person(s)or firms who are financially responsible for this land-disturbing activity: (use blank page to list additional
person(s)or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership***
Name of Person or Firm: SHEETZ, INC.
Street Address/PO Box: 5700 SIXTH AVE
City/State/Zip Code: ALTOONA, PA 16602
Office Phone: [phone] Mobile Phone: Fax#:
If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent:
Name of Registered Agent CORPORATION SERVICE COMPANY
Street Address/PO Box•2626 GLENWOOD AV, SUITE 550
City/State/Zip Code:RALEIGH, NC 27608
Office Phone: Mobile Phone: Fax#:
If the financially responsible party is a partnership,provide information for each General Partner:
(use blank page to list additional partners if needed)
Name of Registered Agent:
Street Address/PO Box:
City/State/Zip Code:
Office Phone: Mobile Phone: Fax#:
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 their attorney-in-fact,or if not an individual,by an officer,
director,partner,or registered agent with 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.
Type or Print Name: Brian Dinges
Title or Authority: Vice President of Real Estate
Signature: Date: - 5 - dodgy{
I, .........nt S W VaC la~ ,a Notary Public of the County of 1..1a1`
State of LI\1)51 G()lgt ,do hereby certify that .... .�.Re -J , 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 day of I-2r u c\l ` ,201 �...
Notary Public Name: NY:\A"-k-0 \)(2.
Commonwealth of Pennsylvania•Notary Seal
/� Andrew J.Podolak,Notary Public
Notary Public Signature: .(rt4L 11t°41L..,r��e....&1ft.fl Blair County
My commission expires July 19,2027
My commission expires: J 19. g,0-) l f Commission nn�umIber 1435770
Rd�
Member, 6ilirt�' ►oclatIon of Notaries