NCC242258_FRO Submitted_20240724

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Attach a copy of the Letter hilIRASI7L193540A
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM CZOZ 6 Z d3S
SEDIMENTATION POLLUTION CONTROL ACT
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No person may initiate any land disturbing activity on one or more acres as coveredktilt
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activity under a common plan of development of this size as covered by the NCGO1 er i , ore s-t m
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.) a).R
Part A. 1 - 2-1-1"- ou3
-I. Project NameChick-fil-A Elkin FSU #04437
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
n/a
2. Location of land disturbing activity: CountySUrry City or Township Elkin
CC Camp Road 36.278383 -80.834611
Highway/Street Latitude degrees) Longitude)decimal degrees)
3. Approximate date land-disturbing activity will commence: 1/1/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .15 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-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameAndrea Gonzalez E-mail [e-mail]
Phone: Office# 980-446-3307 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
JEMSITE DEVELOPMENT LLC
Name Phone: Office # Mobile#
PO BOX 1000
Current Mailing Address Current Street Address
JEFFERSON NC 28640-0000
City State Zip City State Zip
10. Deed Book No. 01 208 Page No. 1021 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).
Chick-fil-A, Inc. [e-mail]
Company Name E-mail Address
160 Mine Lake Ct Suite 200 160 Mine Lake Court Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office# 704 449 4530 Mobile#
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:
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)
(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:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct. Suite 200 160 Mine Lake Ct. Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Meghan Caldwell
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
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.
DAVID LI.IGSN �,oa,. M � r
T r print name Title or Authority
` jIrk/11,"01,
Signature Date
I, , a Notary Public of the County of Co 'J'`
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State ofNer efel ^, hereby certify that I)i�1 VI�t 1 i(f C-6(4/- 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 S (,Lt,P , 20 V3
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
CROSLAND BARNES GROUP LLC
Name Phone: Office# Mobile#
PO BOX 1000
Current Mailing Address Current Street Address
JEFFERSON NC 28640-0000
City State Zip City State Zip
Deed Book No. 01 208 Page No. 1 021 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.