NCC220715_FRO Submitted_20220210

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 Environmental Quality. Submit the completed form to the
annronriate Poninnal nffiCe (Please tvnojr— nr print anri if thin - iestinn is not annlicabite or the e-mail anril
or fax information unavailable, place N/A in the blank.)
Part A. Faircloth Gas Station
1. Project Name
VA
3.
4.
5.
6.
Location of land -disturbing activity: County City or Township Mclauchlin
Highway/Street NC Hwy 401 Latitude 35.031326 Longitude -79.101113
Approximate date land -disturbing activity will commence: January 15, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.7ac
Amount of fee enclosed: $ 800.00 . 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).
Hoke
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 Dan Farrell E-mail Address daneiandkbuilders.com
Telephone [phone] Cell # 910-684-0648 Fax #
p7
Landowner(s) of Record (attach accompanied page to list additional owners):
Johnson Mill Shops_, LLC 910-248-6464
Telephone Fax Number
645 Laurinburg Highway
Current Street Address
Raeford NC 28376
Name
645 Laurinburg Highway
Current Mailing Address
Raeford NC 28376
City
10. Deed Book No
1342
State
Zip City
Page No. 33
State
Zip
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.
Johnson Mill Shops, LLC [e-mail]
Name E-mail Address
645 Laurinburg Highway 645 Laurinburg Highway
Current Mailing Address
Raeford NC 28376
City State Zip
Telephone [phone]
Current Street Address
Raeford NC 28376
City
Fax Number
State
Zip

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
Telephone
E-mail Address
Current Street Address
State 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:
Name of Registered Agent
Current Mailing Address
City
Telephone,
State
Zip
E-mail Address
Current Street Address
City State Zip
Fax Number
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.
Mubarak Shahb
ain
Type or print na e
ignature
Manager
Title or Authority
c/zz Zi
Date
I, �1fi�`(i�,�C� LJ1iC� r� a Notary Public of the County of ­';n d,
State of North Carolina, hereby certify that lu Lxe«V v��h 1�Cti0- 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 _a day of '�, 464U 20
Seal _ =
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Notary
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