HomeMy WebLinkAboutNCC222053_FRO Submitted_20220602FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 NIA in the blank.)
Part A.
1. Project Name Dollar General - Albemarle
2. Location of land -disturbing activity: County Stanly City or Township Albemarle
Highway/Street W. Main Street Latitude 35.337018 Longitude -80.226276
3. Approximate date land -disturbing activity will commence: March 2022
4, Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.15 acres
6. Amount of fee enclosed: $ 400+ 1000 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next 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).
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 Joe Strickland E-mail Address jstrickland@teramore.net
Telephone 704-224-7364
Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
JEP Farms, LLC
Name Telephone Fax Number
20711 St. Martin Road 20711 St. Martin Road
Current Mailing Address Current Street Address
Albemarle NC 28001 Albemarle NC 28001
City State Zip City State Zip
10, Deed Book No. 907 Page No. 875 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.
Teramore Development. LLC jstrickland@teramore.net
Name E-mail Address
214 Klumac Road Suite 101 214 Klumac Road Suite 101
Current Mailing Address Current Street Address
Salisbury NC 28144 Salisbury NC 28144
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:
Joe Strickland
jstrickland@teramore.net
Name of Registered Agent
E-mail Address
214 Klumac Road Suite 101
214 Klumac Road Suite 101
Current Mailing Address
Current Street Address
Salisbury NC28_144
Salisbury NC 28144
City State Zip
City State Zip
Telephone 704-224-7364
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;
BREC, PA
Justin@brec.biz
Engineering firm or other consultant
E-mail Address
Justin Church, PE
336-844-4088
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.
Joe Strickland
DPO-or tint name
re
Member
Title or Authority
/- �0A2
Date
Q 4 "" r t f /f, L/11,4 7,1 N , a Notary Public of the County of
State of North Carolina, hereby certify that _)G S 7-4 FCI<L'fA14
before me this day and being duly sworn acknowledged that the above form a
Witness my hand and notarial seal, this day of f IF d A-c
CAFJp p�RY'PUBLiC
Rowan County
North Carolina
P4V Cornmission Fa!pifes June 25, 201
L appeared personally
executed by him.
200 Z
Notary
My commission expires Z) U N f -L Z o 2