NCC241876_FRO Submitted_20240619

redfae�, FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of V1C SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
outhern Ines 140 Memorial Park Court
r{a ,14 NorthCaroIin, Southern Pines, North Carolina 28387
- The slid South Rexxt
Intcrnntionally Recognized for Program Excellence Telephone: [phone] — Fax: [phone]
No person may initiate any land-disturbing activity greater than 30,000 sq. ft. (including lots or tracts of land that are
a part of a Common Plan of Development that the total disturbance will exceed 30,000 sq. ft.)as covered by the
Town's Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been
completed and approved by the Town of Southern Pines. (Please type or print and, if the question is not applicable
or information unavailable, place N/A in the blank.)
Part A.
1. Project Name: Valvoline Southern Pines
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address 1715 Hwy US 1 South, Southern Pines, NC 28387
3. Latitude: 35.157642 Longitude: -79.412433 PIN: 00053109
4. Percent Impervious: 49.7%
5. Approximate date that land-disturbing activity will commence: 6/5/2024
6. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.88 Acres
8. Amount of fee enclosed: $
The application fee is $300.00 for the first acre plus $150.00 for each additional acre, or part thereof.
The revised plan review fee is $50 for each submittal after the 2"d review.
Any substantial revision to a previously approved, active plan is $50 per acre, or part thereof.
No Fee for Minor Construction Activities less than 30,000 sq. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
[e-mail] &
Name Paul Lawler, PE E-mail Address jrayfield@hnwman nom
Telephone [phone] Cell # 864-607-2159 Fax#
10. Landowner(s) of Record (attach accompanied page to list additional owners):
J.R. HOLDINGS GROUP, LLC 910-417-7550
Name Telephone Fax#
100 Magnolia Road, Suite 300 100 Magnolia Road. Suite 300
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
11. Deed Book No. 6075 Page No. 528-531 (Provide a copy of the most current deed).

Part B.
1. Person(s)or firm(s)who is financially responsible for the land-disturbing activity
(Provide a comprehensive list of all responsible parties on an attached sheet):
Southeast Quality Auto, LLC [e-mail]
Name E-mail Address
8000 Tower Point Drive 8000 Tower Point Drive
Current Mailing Address Current Street Address
Charlotte NC 28227 Charlotte NC 28227
City State Zip City State Zip
Telephone [phone] Fax#
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:
Name of Registered NC Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax#
(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:
Matt McKeown (Corporation Service Company) [e-mail]
Name of NC Registered Agent E-mail Address
4224 Princeton Avenue 4224 Princeton Avenue
Current Mailing Address Current Street Address
Greensboro NC 27407 Greensboro NC 27407
City State Zip City State Zip
Telephone [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 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.
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Type r ptint name Title or Authority
/' I 03 1 I S 702-4
Signature Date
I,` I 'C INe S . V\Nic2 k___CL. , a N tary Public of the Count of lA nyt,l (5
State of North Carolina, hereby certify that I (,0 n1C-k
appeared personally before me this day and being duly acknowledged that the above form
was executed by him. ,�}f�
Witness my hand and notarial seal, this t,`� day of , 20 o.T
I ROXANNE 5 MYSZKA I
I Notary Public-North Carolina
Union County 1 Notary
Seall My Commission Expires Jul 25, 2027
My commission expire -��y n��l aka .
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9,2020