NCC221181_FRO Submitted_20220331

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
Noperson may initiate any land -disturbing activity on one or more acres as covered '�&�������
form and an acceptable erosion and sedimentation control plan have been completed and approved bythe
Land Quality 8euion, N.C. Department of Environment and Natural Resources. (Please type or print md. if
the question is not applicable or the e-mail and/or fax information unavailable, placeN/A inthe b|onk)
Part A.
1. Project Name ABC Store No. 4 and Warehouse
2. Location ofland-disturbing activity: Count -City or Tovvnehi Bridgeton
Highway/Street
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
H. Amount offee enclosed: The Express Permitting application fee is adua| charge.
The normal fee mf$G5.00 per acne is oaoemmed 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: Q aunae total is $2.585). NOTE: Both #aen are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has anerosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address
Telephone Cell # Fax# [phone]
A. Landowner(s) of Record (attach accompanied page to list additional owners):
Craven County ABC Board 252.638.1318 252.514.2389
Name Telephone Fax Number
3493 Martin Drive
Current Mailing Address Current Street Address
New Bern, NC 28562
City ooamo Zip City State Zip
10. Deed Book No.3595 PuoeNo1678;Deed Book No.3595 Page No.16K81.;and Deed Book Nn.3699
PageNu.431 Provide acopy ofthe most current do*d.
Par0B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list ofall responsible parties nnenattached aheet):
Craven County ABC Board ccabc(a-)suddenlinkmail.com
Name E-mail Address
3493 Martin Drive
Current Mailing Address Current Street Address
New Bern, NC 28562
City State Zip city State Zip
Telephone Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Avolis Engineering, PA avolisengineering(cD-embargmail.com
Engineering Firm or other consultant E-mail Address
J. Kevin Avolis, PE 252-633-0068
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.
or print name
Chairman, ABC Board
Title or Authority
�/q) f
Date
I, 34h e-r- _t3, " 244r_ r -s o _,a Notary Public of the County of CrcLVC_�
State of North Carolina, hereby certify that W j ffye J. k. ChAnOA 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 SePl-' Yyxi Dele- 120Jf
A
Notary
Seal
My commission expires &e 41 .202Z