NCC216802_FRO Submitted_20211209

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 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.
Project Name Dollar General
2. Location of land -disturbing activity: County Franklin City or Township Franklinton
Highway/Street 2126 Pocomoke Rd. Latitude 1b36.081034 Longitude W-78.5398
3. Approximate date land -disturbing activity will commence: _Dece_M- ber 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.); QmmercIg
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.76
6. Amount of fee enclosed: $ 195.00 . 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).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George Barnes -Vanguard Ventures, LLC E-mail Address barnes(ED_vanguardlog.com
Telephone 1919-)_459-2601 Cell # Fax# [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Ste hen Dou las Gourley_
Name Telephone
2142 Pocomoke Rd.
Current Mailing Address Current Street Address
Franklinton NC 27525 _
City State Zip City
State
Fax Number
10. Deed Book No. RE 1885 Page No.633 Provide a copy of the most current deed. "`Attached
Part B.
Zip
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
George Barnes -Vanguard Ventures. LLC
Name
_3825 Barrett. Dr., Ste. 100
Current Mailing Address
barnes v n uard .corn
E-mail Address
Current Street Address
_Raleigh NC _27609
City State Zip City State Zip
Telephone( 19) 4 9-2601 Fax Number 91 459-2 04

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
Telephon
E-mail Address
Current Street Address
Zip 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:
Sherri Hepps, Glandon Forest Equity, LLC
Name of Registered Agent
3825 Barrett Dr., Suite 100
Current Mailing Address
sheops[ayanquard o.com
E-mail Address
Current Street Address
Raleigh, NC 27609
City State Zip City
State Zip
Telephone [phone] Fax Number [phone]
The above information is true and correct to the best of my knowledge and belief and was provided
by me urider 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.
Ge r e I, Barnes -member/manager
Type or pr' e Title or Authority
y Ise is,
Signature Date
I, Ni MU Lai Nn" a Notary Public of the County of VrcL��,�an
State of North Carolina, hereby certify that �QnrCA boy— l.-s appeared
personally before me this day and being duly swofti acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 2b day of , 20 Zj
RY Notary
Ew�H v My commission expires CLJ-05 - 23
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