NCC241835_FRO Submitted_20240614

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Outback Steakhouse/Caribou Coffee Development
2. Location of land-disturbing activity: County Forsyth City or Township Kernersville
Union Cross Rd.&Glennview Dr. 36.0728 N -80.1099 W
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 04/01/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.2
6. Amount of fee enclosed $1 ,450 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre(rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). 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 Chris Clayton - Mount Oak Capital E-mail Address [e-mail]
Phone: Office# 919-604-4474 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
MOC Kernersville, LLC 919-604-4474 919-604-4474
Name Phone: Office# Mobile#
500 6th Street 500 6th Street
Current Mailing Address Current Street Address
San Antonio TX 78215 San Antonio TX 78215
City State Zip City State Zip
10. Deed Book No. 3789 Page No.45 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).
MOC Kernersville, LLC [e-mail]
Company Name E-mail Address
500 6th Street Same as mailing address
Current Mailing Address Current Street Address
San Antonio TX 78215
City State Zip City State Zip
Phone: Office# 919-604-4474 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:
Northwest Registered Agent Service, Inc. [e-mail]
Name of Registered Agent E-mail Address
4030 Wake Forest Road, Suite 349 Same as mailing address
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Phone: Office#509-768-2249 Mobile#
JM Spear
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:
Northwest Registered Agent Service, Inc. [e-mail]
Name of Registered Agent E-mail Address
4030 Wake Forest Road, Suite 349 Same as mailing address
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Phone: Office# 509-768-2249 Mobile#
JM Spear
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
The Nau Company [e-mail]
Engineering firm or other consultant E-mail Address
Jeremy Beckett 919-395-2775 919-395-2775
Individual contact person (type or print) Phone: Office# Mobile#
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.
Chris Clayton Design & Permitting Director
Typ r p int name Title or Authority
S , 2/13/24
S ure Date
I, b/�ICU YtA L& rn j vl0 V , a Notary Public of the County of f
State of North Carolina, hereby certify that cs,,,K;s pkar ClA on appeared personally
before me this day and being duly sworn acknowledged that the abo 1e form was executed by him/her.
Witness my hand and notarial seal, this 13 day of -i b , 200y
Veronica M.Saghir O /C,
NOTARY PUBLIC Notary
County,NC
My Commission Expires 8-25-2027.
Seal My commission expires DEla.Sia0d-7