NCC221315_FRO Submitted_20220407

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
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. Hardee's at Cliffdale
1. Project Name
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street Cliffdale Road Latitude35.05933 Longitude-79.04768
3. Approximate date land -disturbing activity will commence:Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .09
6. Amount of fee enclosed: $ 200.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Varnell E-mail Address [e-mail]
Telephone[phone] cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Boddie -Noel) Enterprises, Inc
252-937-2800 252-937-4909
Name
Telephone Fax Number
PO Box 1908
1021 Noell Lane
Current Mailing Address
Current Street Address
Rocky Mount NC 27802
Rocky Mount NC 27804
City State Zip
City State Zip
10. Deed Book No. 1 1088 Page No.507 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.
Boddie -Noel) Enterprises, Inc
[e-mail]
Name
E-mail Address
PO Box 1908
1021 Noell Lane
Current Mailing Address
Current Street Address
Rocky Mount NC 27802
Rocky Mount NC 27804
City State Zip
City State Zip
Telephone [phone]
Fax Number252-937-4909

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
Current Mailing Address
City State
Telephon
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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.
Michael H. Han ock Executive VP
Type ri name Title or Authority
Feb. 2, 2022
Sig ature Date
Donna S. Batchelor Nash
a Notary Public of the County of
State of North Carolina, hereby certify that Michael H. Hancock, Ex. VP of Boddie -Noel) Enterprises, Inc.
ared
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 2 day of February 2022
DONNA S. BATCHELOR
NOTARY PUBLIC
;,_HASH COUNTY, N.C. Notary
Seal
My commission expires May 23, 2022