SW7961115_CURRENT PERMIT_20210608

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW AU/Z
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
,�A ld�l09
YYYYMMDD

tj01V-°
ROY COOPER
Governor
JOHN NICHOLSON
Interim Secretary
BRIAN WRENN
Director
Hoffer Properties, LLC
Attention: Mamie Hoffer
107 Kitty Hawk Lane
Elizabeth City, NC 27909
NORTH CAROLINA
Envfrontnental Quality
June 8, 2021
Subject: Stormwater Permit No. SW7961115 Renewal
Hoffer Center Parking Lot Expansion
High Density Stormwater Project
Pasquotank County
Dear Mamie Hoffer:
The Washington Regional Office received a Stormwater Management Permit
Application for renewal of the subject permit on May 7, 2021. Staff review of the
application has determined that the permit can be reissued. We are forwarding Permit
No. SW7961115 dated June 8, 2021, for the continued operation of the existing
stormwater system.
This permit, upon its effective date, will replace all previous State Stormwater permits for
this project. This permit shall be effective from October 26, 2021 until October 25, 2029
and shall be subject to the conditions and limitations as specified therein, and does not
supercede any other agency permit that may be required. Please pay special attention to
the Operation and Maintenance requirements in this permit. Failure to establish an
adequate system for operation and maintenance of the stormwater management system
will result in future compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you
have the right to request an adjudicatory hearing upon written request within thirty (30)
days following receipt of this permit. This request must be in the form of a written petition,
conforming to Chapter 150B of the North Carolina General Statutes, and filed with the
Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714.
Unless such demands are made this permit shall be final and binding.
If you have any questions, or need additional information concerning this matter, please
contact me at [phone].
Sincerely,
�! Roger K. Thorpe
Environmental Engineer
..- North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
_ � Washington Regional Office 1 943 Washington Square Mall I Washington, North Carolina 27889
nornvumau ` _'
' 252.946.8481

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North
Carolina as amended, and other applicable Laws, Rules and Regulations
PERMISSION IS HEREBY GRANTED TO
Hoffer Properties, LLC
Hoffer Center Parking Lot Expansion
Located on Industrial Park Drive, Elizabeth City, NC
Pasquotank County
FOR THE
construction, operation and maintenance of a wet detention pond in compliance with the
provisions of 15A NCAC 2H .1000 (hereafter referred to as the "stormwater rules") and
the approved stormwater management plans and specifications and other supporting
data as attached and on file with and approved by the Division of Energy, Mineral, and
Land Resources (Division) and considered a part of this permit.
This permit shall be effective from October 26, 2021 until October 25, 2029, and
shall be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. The total project site contains 5.62 acres. This stormwater system has been
approved for the management of stormwater runoff as described in Section 1.6 of
this permit. The wet detention pond has been designed to handle the runoff from
73,363 square feet of impervious area.
3. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
4 The runoff from all built -upon area within the permitted drainage area # 1 of this
project must be directed into the permitted stormwater control system.
— '. North Carolina Department of Environmental Quality I DMsion of Energy, Mineral and land Resources
J/ Washington Regional Office 1 943 Washington Square Mall I Washington, North Carolina 27889
rvamnrsraau //
252.946.6481

5. The built -upon areas associated with this project shall be located at least 50 feet
landward of all perennial and intermittent surface waters.
6. The following design criteria have been provided for Drainage area # 1. The wet
detention pond must be maintained at design condition:
a. Drainage Area,ft2
b. Total Impervious Surfaces, ft2:
C. Design Storm, inches:
d. Average Pond Depth, feet:
e. TSS removal efficiency:
f. Permanent Pool Elevation, FMSL:
g. Permanent Pool Surface Area, ft2:
h. Permitted Storage Volume, ft3:
i. Temporary Storage Elevation, FMSL:
j. Predevelopment 1 year 24 hour:
k. Post development 1 year 24 hour:
I. Controlling Orifice:
M. Permitted Forebay Volume, ft3:
n. Receiving Stream/River Basin:
o. Stream Index Number:
P. Classification of Water Body:
115,211
73,363
1.5
3.31
90%
3.5
8,454
11,594
4.60
6.71 cfs
1.07 cfs
1.25 "0
3,999
Charles Creek/ Pasquotank
30-3-(11)
"C-Swp"
In addition to the above, there is 31,967 sf of built -upon area in drainage area # 2
located along the eastern side of the property that does not flow into the wet detention
pond. This results in a total of 105,330 sf of built -upon area allowed.
II. SCHEDULE OF COMPLIANCE
The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted stormwater system functions at optimum efficiency. The
approved Operation and Maintenance Plan must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the vegetated filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans and
specifications.
f. Debris removal and unclogging of outlet structure, orifice device, level
spreader, filter strip, catch basins and piping.
g. Access to the outlet structure must be available at all times.
IeK— �Z North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
Washington Regional Office 1 943 Washington Square Mall I Washington, North Carolina 27889
252946.648I

5.
Records of maintenance activities must be kept for each permitted BMP. The
records will indicate the date, activity, name of person performing the work and
what actions were taken.
Access to the stormwater facilities shall be maintained via appropriate
easements at all times.
6. The facilities shall be constructed as shown on the approved plans. This permit
shall become void unless the facilities are constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other
supporting data.
Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the system installed certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A
modification may be required for those deviations.
8. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
9. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
10. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
�tt North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
_ 1/ Washington Regional Office 1 943 Washington Square Mall I Washington, North Carolina 27889
252.946,6481

11. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
12. A copy of the approved plans and specifications shall be maintained on file by
the Permittee at all times.
III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form, to the Division of Energy,
Mineral, and Land Resources, signed by both parties, and accompanied by
supporting documentation as listed on page 2 of the form. The project must be in
good standing with the Division. The approval of this request will be considered
on its merits and may or may not be approved.
The permittee is responsible for compliance with all permit conditions until such
time as the Division approves the transfer request.
Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Energy, Mineral,
and Land Resources, in accordance with North Carolina General Statute 143-
215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation of
nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DEQ Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
Washington Regional Office 1 943 Washington Square Mall I Washington, North Carolina 27889
o..ru..unw� /"� 252.946.6481

10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Title 15A NCAC
2H.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division of any name, ownership or mailing address
changes at least 30 days prior to making such changes.
12. This permit shall be effective from October 26, 2021 until October 25, 2029.
Application for permit renewal shall be submitted 180 days prior to the expiration
date of this permit and must be accompanied by the appropriate processing fee.
Permit issued this the 8 th day of June 2021.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
For
Brian Wrenn, Director
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Permit Number SW7961115
�DFNorth Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
Washington Regional Office 1 943 Washington Square Mall I Washington, North Carolina 27889
252946.6481

' - DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
o5 CYc
r rt G 111S
NC DEQ Division of Energy, Mineral and Land Reso y IE fB T 0 M T D
STATE STORMWATER: lLS l�/ LS
PERMIT RENEWAL APPLICATION FOR
In accordance with 15A NCAC 2H 1045(3), the current permit holder shall renew their high density permit 180 days
prior to its expiration. Renewed permits are valid for a period of 8 years per Session La� 11-398 (SB 781)
Section 60. (c). This application form is for permit renewals only. l n l X m ;; _
A. PROJECT INFORMATION
1. State Stormwater Permit Number:
2. Project name:
3. Project street address:
City: e\1 Lc.bO - 4
LAD
County:
4. What, if any, changes have been made to the project as permitted?
RAY Q 7 2gZ,
A-1910 1
If the project has changed from the original approved plans, please complete SWU-101 fora Major
Modification or Minor Modification Application form available at: https'//deg.nc.gov/about/divisions/energy-
mi neral-land-resources/energy-mi nera I-land-rules/stormwater-prop ram/post-construction.
B. PERMITTEE INFORMATION
If changes to the permittee or project name have been made, please complete either the Permit Update form
or the Permit Transfer form available at. https://deg.nc.gov/about/divisions/energy-mineral-land-
resources/energy-mineral-land-rules/stormwater-program/post-construction State Stormwater Permits do not
automatically transfer with the sale of the property.
1. Current Permit Holder's Company Name/Organization: �A--Kew k"royevmie %. LLC
2 Signing Official's Name: (\ uXiAie- li e- ! v
3. Signing Official's Title: .P�. iigt
4. Mailing Address: _ ,0-1 UIC V— Lah 2
City:
5. Street Address:
City: (: &&
6. Phone. (ael1619 Email.
Imo f-rc
NXzip 2'111O1
NC` zip: a>9oS
Stormwater Permit Renewal Form Page 1 of 3 May 11, 2018

C. SUBMITTAL REQUIREMENTS
Sutimit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non -Coastal HQW/ORW). Only applications packages that
include all required items listed below will be accepted and reviewed.
Initial each item below to indicate that the required information is provided in the application package:
1. A permit application processing fee of $505.00 payable to NCDEQ.
2. _One.o7iginal,sig'ned hard copy and one electronic copy of this completed form. The signing official
t" named on this,application to represent the current permittee must meet one of the following
} a. Corporation'— a principle executive officer of at least the level of vice-president;
b. Limited Liability Company (LLC) — a manager or company official as those terms are defined
t in G.S. 57D "North Carolina Limited Liability Company Act;"
c. Public Entity — a principal executive officer, ranking official, or other duly authorized employee,
1 d. Partnership or limited partnership — the general partner;
t e. Sole proprietor; or
f. Letter of authorization signed by one of the signatories- noted in a — e above authorizing the
signature of another entity
3. One hard copy and one electronic copy of recorded documents required by the original permit that
have not yet been received by DEMLR, including. deed restrictions, protective covenants,
condominium/planned community declaration and easements. If the project has been built, include
documentation that the maximum BUA per lot or maximum total BUA has not been exceeded. If
the project has not been built, include a signed agreement that the final recorded deed restrictions
nn 1 and protective covenants will be submitted at a later date.
1 t vV� 4. O&M Agreements, Please select one
❑ 1 have a copy of the current recorded O&M Agreement for all SCMs, and I will continue to
keep this on file with the permit; or
I do not have a copy of the current recorded O&M Agreement for all SCMs and am
p requesting a copy be sent to me. I agree to keep this on file with the permit.
N A 5. Designer Certifications, Please select one:
❑ A copy of the certification(s) confirming that the project was built in accordance with the
approved plans have been previously provided to the Division; or
❑ A copy of the certification(s) confirming that the project was built in accordance with the
approved plans are enclosed; or '
❑ The project has not yet been built.
NI Q� 6. [IF APPLICABLE] If the project has been built, one original hard copy and one electronic copy of a
signed, sealed, and dated letter from a licensed professional stating that the SCMs have been
inspected, and that they have been built and maintained in accordance with the permit.
7 [IF APPLICABLE] When the permittee is a corporation or a limited liability corporation (LLC).
Provide one hard copy and one electronic copy of documentation from the NC Secretary of State,
or other official documentation, which supports the titles and positions held by the persons listed in
Section C.2 per 15A NCAC 2H. 1043(3)(b).
httos://www.sosnc.gov/online services/search/by title/ Business Registration
Stonnwater Permit Renewal Application Form Page 2 of 3 May 11, 2018

D. PERMITTEE'S CERTIFICATION
I, INAL-M*1 C �i t f- , the person legally responsible for the permit, certify that I have
a copy of the Permit and O&M Agreement on site (or I will obtain a copy and it will be kept on site), that I am
responsible for the performance of the maintenance procedures, and the site has been and will be maintained
according to the O&M Agreement and approved plans. I agree to notify DEMLR of any problems with the SCMs
or built -upon area and to submit the proper forms to modify or transfer the permit prior to any changes to the
project, SCMs, or ownership. All information provided on this permit renewal application is, to the best of my
knowledge, correct and complete.
Signature: 1?'� Date: 4 ��
NOTARIZATION'
t, Q.vt_ 13.
a Notary Public for the State of
do hereby certify
v
that personally appeared before me
this the olt.4 day of 6pv i .20 a \ , and acknowledge the due
execution,of the forgoing instrument. Witness my hand and official seal,
County of
(Aiotary Seaq
Notary Signature: I y olA e 0
✓ c .
My commission expires a ick - aoa3
Stormwater Permit Renewal Application Form Page 3 of 3 May 11, 2018

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(91LIMITED LIABILITY COMPANY ANNUAL REPORT
4
IW2ou
NAME OF LIMITED LIABILITY COMPANY: Hoffer Properties, LLC
SECRETARY OF STATE ID NUMBER: 0644509 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 2021
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Hoffer, Kenneth R.
2. SIGNATURE OF THE NEW REGISTERED AGENT:
E - Filed Annual
Report
0644509
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
107 Kitty Hawk Lane 107 Kitty Hawk Lane
Elizabeth City, NC 27909 Pasquotank County Elizabeth City, NC 27909
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS:
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] ':- t 3..PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS ' 5. PRINCIPAL OFFICE MAILING ADDRESS
107 Kitty Hawk Lane 107 Kitty Hawk Lane
Elizabeth City, NC 27909 Elizabeth City, NC 27909
6. Select one of the following if applicable. (Optional see instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Kenneth R. Hoffer NAME: Kenneth R. Hoffer NAME: Mamie E. Hoffer
TITLE: Manager TITLE: Member
ADDRESS:
ADDRESS:
TITLE: Member
ADDRESS:
158 E. Camp Perry Road 158 E. Camp Perry Road 158 E. Camp Perry Road
Hertford, NC 27944 Hertford,.NC 27944. Hertford, NC 27944
SECTION D
CERTIFICATION OF ANNUAL REPORT.'Section D must be completed in its entirety by a person business entity.
Mamie E. Hoffer 4/1/2021
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
DATE
Mamie E. Hoffer Member
Print or Type Name of Company Offical Print or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525. Raleigh, NC 27626-0525

-5- `-V hfofA--r C-O" %r
M
r` ASTER N
'� CAROLZNA
ENGINEERING. P.C.
August 22, 2017
Mr. Roger Thorpe, PE
Dept. of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section
943 Washington Square Mall
Washington, NC 27889
Subject: Engineer's Certification
Hoffer Center — Parking Lot Expansion
Permit No. SW 7961115
ECE Project. #170061
Dear Mr. Thorpe:
Enclosed please find the Designer's Certification for the above referenced project. Please note
that, while I was not the designing engineer, I have access to the original design plans prepared
by Hyman & Robey, PC. The pond has been found to have been constructed in compliance
with the design plans.
If you have any questions, please do not hesitate to contact this office at [phone].
Sincerely,
Ef
stern Carolina Engineering,, P,C— j /
berly D. Hamby, PE l�
Vice President - Engineering
cc: file
Eastern Carolina Engineering, PC
P. O Box 128 Camden, North Carolina 27921
[phone] License C-4162
w .easterncarolinaengineenng.com

Hoffer Center Parking Lot Expansion — Elizabeth City, NC
Stormwater Permit No. SW7961115
Pasquotank County
Designer's Certification
Kimberly D. Hamby , as a duly registered Professional Engineer in the
State of North Carolina, having been authorized to observe
time) the construction of the project, after completion
Hoffer Center - Parking Lot Expansion
(Project)
for Hoffer Properties, LLC (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of.this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature�J�k .—�b��
Registration Number •4I 9
Date e l a �2
CqR'"
s2tQ� SEAL29�t9!+
�;•�042614�'!� •

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r
J'6 -5w7 9d // 15-2
�Frcvvl b6
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT o %ZD/ l-S
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 Environment and Natural Resources. (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.
1. Project Name Hoffer Center Parking Lot Expansion
2. Location of land -disturbing activity: County PaSquotank city or Township Elizabeth City
Highway/Street Industrial Park Dr. Latitude36.2754 Longitude-76.2136
3. Approximate date land -disturbing activity will commence: October 15, 2013
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.00 aC
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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kenneth Hoffer E-mail Address [e-mail]
Telephone [phone] cell # 252-202-6682 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hoffer Properties, LLC 252-331-1997 252-331-2886
Name Telephone Fax Number
107 Kitty Hawk Drive
Current Mailing Address
Elizabeth City NC 27909
City
10. Deed Book
Part B.
1
State Zip
107 Kitty Hawk Drive E C E N V l_ D
Current Street Address SEp I 12013
Elizabeth City NC 2790
City State LAN secnoN
WASHIN REGIONAL OFFICE
738 Page No. 302 Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing
comprehensive list of all responsible parties on an attached sheet):
Hoffer Properties, LLC [e-mail]
Name E-mail Address
107 Kitty Hawk Drive 07 Kitty Hawk Drive
Current Mailing Address Current Street Address
activity (Provide a
Elizabeth City NC 27909 Elizabeth City NC 27909
aty
State Zip
Telephone [phone]
City State
Fax Number 252-331-2886
r"

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:
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
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:
Name of Registered Agent
rrent Mailing Address
State Zip
E-mail Address
Current Street Address
City State Zip
Fax
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.
Kenneth R. Hoffer
Manager
Type rint name Title or Authority
-� � I �]3
Signature Date
1, �-r A. Ali a_Lz , a Notary Public of the County of _f7A6Q%3aV, *_
State of North Carolina, hereby certify that AeWKk!rM 4. A/oFF�'L 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 day of -, ULy , 20_L5
JASOPt MIZELLE
NOTA PUBLIC
PASQUOTANK COUNTY, N.C.
AotaryL#
My commission expires QLA-) SI eZ-e_)l!S