NCC242263_FRO Submitted (2)_20240725

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Dollar General - Mocksville Store #30457
2. Location of land-disturbing activity: County Davie City or Township Mocksville
Highway/Street TBD US Hwy 64 W Latitude(decimal degrees)35.9044 Longitude(decimal degrees)-80.6900
3. Approximate date land-disturbing activity will commence: May 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.11 acres
6. Amount of fee enclosed: $300.00 . 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 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Joe Strickland E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Sam Howard Farm Inc.
Name Phone: Office# Mobile#
814 People Creek Road 814 People Creek Road
Current Mailing Address Current Street Address
Advance, NC 27006 Advance, NC 27006
City State Zip City State Zip
10. Deed Book No. 1217 Page No. 1190 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).
Teramore Development, LLC [e-mail]
Company Name E-mail Address
214 Klumac Road Suite 101 214 Klumac Road Suite 101
Current Mailing Address Current Street Address
Salisbury NC 28144 Salisbury NC 28144
City State Zip City State Zip
Phone: Office# 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:
Joe Strickland [e-mail]
Name of Registered Agent E-mail Address
214 Klumac Road Suite 101 214 Klumac Road Suite 101
Current Mailing Address Current Street Address
Salisbury, NC 28144 Salisbury, NC 28144
City State Zip City State Zip
Phone: Office# 980-432-8040 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:
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)

(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.
Joe Strickland Registered Agent
Type or pr.,tname Title or Authority
Siga ture Date
'L '1- -,v , a Notary Public of the County of
State of North Carolina, hereby certify that 75Th s tit En"- appeared personally
before me this day and being duly sworn acknowledged that the above was executed by him/her.
Witness my hand and notarial seal, this OP"f day of .164r , 20
•
DANIEL R.ALMAZAN - G� %i---
NOTARY PUBLIC Notary
Rowan County
North Carolina , -uvirL 2_
My Commission Expires June 28,2027 My commission expires �f 2- c 2