NCC221012_FRO Submitted_20220317

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Family Dollar - Elizabeth City, NC
1. Project Name
2. Location of land -disturbing activity: CountyPasquotank City or Township Elizabeth City
Highway/Street Highway 158 Latitude 36.41556N Longitude-76.34389W
3. Approximate date land -disturbing activity will commence: March 7, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):2.29
6. Amount of fee enclosed: $4,300 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Douglas S. Burr E-mail Address [e-mail]
Telephone Cell # 714-929-9331 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Harrell Acquisitions, LLC 252-395-2052
Name Telephone Fax Number
PO Box 688 415 E. Main St
Current Mailing Address Current Street Address
Ahoskie NC 27910 Ahoskie NC 27910
City State Zip City State Zip
10. Deed Book No.1357 Page No. 759(9) Provide a copy of the most current deed.
Part B.
I. 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.
BEL Investments, Elizabeth City, NC, LLC
Name
2862 Dauphin St
Current Mailing Address
Mobile AL 36606
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
2862 Dauphin St
Current Street Address
Mobile AL 36606
City
State
Fax Number 251-460-0206
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:
CT Corporation System
Name
160 Mine Lake Ct.
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone [phone]
E-mail Address
160 Mine Lake Ct.
Current Street Address
Raleigh NC 27615
City State Zip
Fax Number
(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
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant E-mail Address
Individual contact person (type or print) Telephone 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.
eype lean Manger
me�2' Title or Authority
02/14/2022
ature Date
I Andrea Neese , a Notary Public of the County of Mobile
State of North Carolina, hereby certify that Daniel G. EICan 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 144
Seal
day of February
2022
&dM i, ►�I�rr�u
Notary
My commission expires 0512012023
ANOREA L. NEESF
Notary Pubic
Alabama State at Large