NCC242662_FRO Submitted_20240905

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Project JK-88
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Randolph City or Township Randleman
Highway/Street NC HWY 311 Latitude(decimal degrees)35.8231 Longitude(decimal degrees) -79.8493
3. Approximate date land-disturbing activity will commence: August 1, 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial Warehouse
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 216.98
6. Amount of fee enclosed: $ 21,700.00 . 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 le No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Hunter Garrett E-mail Address [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners): See attached sheet
Ross Dress for Less, Inc., a Virginia Corporation [phone]
Name Wade Haddad, Senior VP Phone: Office# Mobile#
5130 Hacienda Drive 5130 Hacienda Drive
Current Mailing Address Current Street Address
Dublin CA 94568-7579 Dublin CA 94568-7579
City State Zip City State Zip
10. Deed Book No. 2914 Page No. 438-449 Provide a copy of the most current deed.
2914 450-457
2914 458-460

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).
H and M Construction Co., Inc./Chris Carroll [e-mail]
Company Name E-mail Address
50 Security Drive 50 Security Drive
Current Mailing Address Current Street Address
Jackson TN 38305 Jackson TN 38305
City State Zip City State Zip
Phone: Office# [phone] 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:
CT Corporation System-Leslie Korhammer [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Ste 200 160 Mine Lake Court, Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 Raleigh NC 27615-6417
City State Zip City State Zip
Phone: Office # [phone] Mobile#
Leslie Korhammer
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 Court, Ste 200 160 Mine Lake Court, Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 Raleigh NC 27615-6417
City State Zip City State Zip
Phone: Office # [phone] Mobile #
Leslie Korhammer
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

(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.
Chris Carroll President
Type r print nam Title or Authority
0.3/21 /
Signature Date
I, , a Notary Public of the County of
State of North Carolina, hereby certify that 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 !5'/May of , 20 A �(
4%% SSE M. . .��� /'
. /(0 Notary
STATE�' s
:TENNESSEE :
My commission ex1pireo�nmisslon expires on:October 22,2025
i NOTARY
'9 %.PUBLIC,':
-"Innit0'