NCC243290_FRO Submitted_20241025

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM P� -}
SEDIMENTATION POLLUTION CONTROL ACT • 1157 ■
WATER RESOURCES•
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105-B Upchurch Street 0 w=77=
Town of Apex, North Carolina 27502 7 .92
OPT
Contact: James Misciagno
Phone: [phone] E-Mail: [e-mail]
No person may initiate any land-disturbing activity on twenty(20)thousand square feet or more before this form has been
completed and filed with the Town of Apex Water Resources Department.
PART A
Name of Project:Dollar Tree-Apex,NC
Location of Land-Disturbing Activity:611 Chessie Station
Approximate Date Land-Disturbing Activity will Commence:10/21/24
Acreage of Land to be Disturbed:1.30
Latitude: 35 44'14.9"N Longitude: 78 50'37.2W
Land Owner(s) of Record (use blank page to list additional owners):
Name:DT Retail Properties,LLC Name:
Current Mailing Address: Current Mailing Address
500 Volvo Parkway
City, State,Zip:Chesapeake,VA 23320 City,State,Zip
PART B
Person or firm financially responsible (developer)for this land disturbing activity. Financial responsibility includes, but
may not be limited to: payment of civil fines and criminal penalties and any other costs associated with bringing the
project into compliance with the Town of Apex Soil Erosion and Sedimentation Control Ordinance.
Name of Person or Firm:DT Retail Properties,LLC
Telephone:[phone] E-mail:[e-mail]
Current Mailing Address: Street Address (if different from mailing address)
500 Volvo Parkway
City, State,Zip:Chesapeake,VA 23320 City,State,Zip
Revised 9/19/2019 Page 1

If the financially responsible party is not a resident of Wake County, complete the following for an appointed agent,in
Wake County, to receive any notice, process,pleading in any action or legal proceeding arising from a violation of the
Town of Apex Soil Erosion and Sedimentation Control Ordinance. By signing below,it is agreed that any notice,process,
or pleading against the person or firm who is financially responsible for this land-disturbing activity may be served on
the undersigned and shall be of the same force and effect as if served on the financially responsible person or firm. The
intent of this provision is to establish the presumption that the constructive notice from the Town of Apex will be
addressed through the undersigned agent.
Name:Corporation Service Company
Telephone:[phone]
Current Mailing Address: Street Address(if different from mailing address)
2626 Glenwood Ave,51le 550
�'igh, NC 27608
City,State,Zip�+ City,State, Zip
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Signature: 'tr�
If the financially responsible party is a partnership or other person engaging in business under an assumed name,complete
Page 4 of this form, or attach a copy of the Certificate of Assumed Name or Partnership as recorded in the Register of
Deeds. If the financially responsible party is a corporation,complete the information on Page 5 of this form and submit a
current copy of the Annual Report as filed with the Secretary of State.
The information contained in this form is true and correct to the best of my knowledge and belief and was provided by
me while under oath. (This form must be signed by the financially responsible person if an individual or by an officer,
director,partner, or registered agent with authority to execute instruments for a corporation or partnership if it is the
financially responsible party). I agree to provide corrected information should there be any change in the information
provided herein.
Name:Todd Littler Date: 10/8/24
Title or Authority:Senior f = President
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Signature: '11117 22�'
I,60W;(0.qA4X i$ a Notary Public of the County of L1~4v" " ` - ,State Vk
of Nortti La-hereb certifythat Lit+tF personallyappeared before me this
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day and under oath acknowledged that�at the above form was executed by him/her. Witness my h pe rf 44his
day of W �P CRY PO. OCP •
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Financial responsibility encompasses personal liability by the person signing this disclosure f'driit'i,tiLiYiiitiler.. in a
partnership or if an officer or director of a corporation which is either:(a)dissolved lawfully under North Ctafb'llna statutes:
(b) suspended from transacting business in North Carolina by the North Carolina Secretary of State, (c) insolvent; (d) in
bankruptcy; (e) undercapitalized to the extent it is unable to comply with the Soil Erosion and Sedimentation Control
Ordinance; or(f) a "shell" corporation.
Revised 9/19/2019 Page 2

PART C
Contractors and/or subcontractors(person(s) or firm(s) engaging in the land-disturbing activity):
Name Person or Firm: Name of Person or Firm:
Epic Construction Services,LLC
Telephone:[phone] Telephone:
Email: Email:
[e-mail],[e-mail]
Current Mailing Address: Current Mailing Address
3812 Tarheel Drive
Suite G
City, State,Zip:Raleigh,NC 27609 City,State,Zip
The information contained in this form is true and correct to the best of my knowledge and belief was provided by me
while under oath. (This form must be signed by the person or firm engaging in the land-disturbing activity of an
individual or by an officer, director, general partner, attorney-in-fact, or other person with authority to execute
instruments for the entity engaging in the land-disturbing activity if not an individual. I agree to provide corrected
information should there be any change in the information provided herein.
Name:Darla Lewis Date: 10/08/2024
Title or Authority:Operations anager
Signature: { l.L'\
l� t/1/4.70 n n e- (cc.tt a Notary Public of the County of W AK--q, ,State of North
Carolina hereby certify that ���� L-�,L s personally appeared before me this
day and under oath acknowledged that the above form was executed by him/her. Witness my hand and seal this
S'41't day of N 6" -c 3�f
SEAL
Nota My Commission Expires
Yvonne Cato
?" ' � NOTARY PUBLIC
t�.. Johnston County, NC
My Commission Expires October 21,2028
Revised 9/19/2019 Page 3

Name of Corporation:DT Retail Properties,LLC
Name of registered agent,street address, mailing address of registered office in Wake County:
Name:Corporation Service Company-Lindsey Eick
Street Address:2626 Glenwood Ave,Suite 550
City, State,Zip:Raleigh,NC 27608
Current Mailing Address:2626 Glenwood Ave,Suite 550
City, State, Zip:Raleigh,NC 27608
Enter first, middle,and last name of principal officers. Enter title and street address of principal officers.
Name and Title: Name and Title:
Todd Littler-Senior Vice President
Street Address: Street Address:
500 Volvo Parkway
City, State,Zip: City, State,Zip:
Chesapeake,VA 23320
Name and Title: Name and Title:
Street Address: Street Address:
City, State, Zip: City, State, Zip:
Enter first, middle,and last name of directors. Enter title and street address of directors. Attach pages as necessary.
Name and Title: Name and Title:
Street Address: Street Address:
City, State,Zip: City, State,Zip:
Name and Title: Name and Title:
Street Address: Street Address:
City, State,Zip: City, State, Zip:
Revised 9/19/2019 Page 5