HomeMy WebLinkAboutNCC215704_FRO Submitted_20211014FINANCIAL 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Discount Tire Store
1. Project Name
2. Location of land -disturbing activity: County Lee City or Township Sanford
Highway/StreetS Horner Blvd _Latitude35.456433 Long itude-79.141291
3. Approximate date land -disturbing activity will commence: 03/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.) Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.84+/- Acres
6. Amount of fee enclosed: $130.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Daniel Nelms E-mail Address Daniel.Nelms@discounttire.com
Telephone 704-910-7917 cell # NA Fax # NA
9 Landowner(s) of Record (attach accompanied page to list additional owners):
William and Jane Murphy 919-622-7486 NA
Name
1802 Tomberlin Rd,
Current Mailing Address
Sanford, NC 27330
City State
10. Deed Book No. 668
Telephone Fax Number
1802 Tomberlin Rd.
Current Street Address
Sanford, NC 27330
Zip City
Page No 239
State
W
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party
Halle Properties LLC, Discount Tire of North Carolina construction@discounttire.com
Name
20225 N Scottsdale Road
Current Mailing Address
Scottsdale AZ 85255
City State
Telephone(480) 606-6000
Zip
E-mail Address
20225 N Scottsdale Road
Current Street Address
Scottsdale AZ 85255
City State Zip
Fax Number(480)-606-4370
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:
NA
Name
NA
Current Mailing Address
NA
City
Telephone NA
State Zip
NA
E-mail Address
NA
Current Street Address
NA
City
Fax Number NA
State Zip
(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:
Danielle Faust, Corporation Service Company danielle.faust@cscglobal.com
Name of Registered Agent E-mail Address
2626 Glenwood Ave. STE 550 2626 Glenwood Ave. STE 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Telephone 1-800-927-9800 Fax Number NA
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.
Matthew Johnson
Type or print name
1 f
Agent
Title or Authority
f ';"-Q�d"Zi
Siri'atur�'- `� Date
Donna M Warner
a Notary Public of the County of Maricopa
State of Arizona, hereby certify that Matthew Johnson appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
DONNA M WARNER
Notary Public
County, Arizons
a . Expires 04-W24
Commisslon No. 581521
day of s , 20 -
Notary
My commission expires 4/6/2024