NCC222447_FRO Submitted_20220707

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. Tabor CityNRetail Development
1. Project Name ew
2. Location of land -disturbing activity: County COIumbUS City or Township Tabor City
Highway/Street Pireway Road Latitude 34 08 23.8 Longitude 78 52 01.4
3. Approximate date land -disturbing activity will commence: 07/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.5
6. Amount of fee enclosed: $ 3G $200 $tooThe application fee of $69.99• per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 WTC of Tabor City, LLC - Jim Price E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ABCD Enterprises, LLC [phone] N/A
10.
Name
209 North Lewis Street
Current Mailing Address
Tabor City NC 28463
city
Telephone Fax Number
209 North Lewis Street
Current Street Address
Tabor City NC 28463
State Zip city
Deed Book No. 718 Page No. 631
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.
WTC of Tabor City, LLC - Jim Price [e-mail]
Name
2240 Sage Valley Drive
Current Mailing Address
Graniteville SC 29829
City State Zip
Telephone [phone]
E-mail Address
2240 Sage Valley Drive
Current Street Address
Graniteville SC 29829
City State Zip
Fax Number N/A

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, Ste 200
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone_(919) 944-4780
E-mail Address
160 Mine Lake Ct, Ste 200
Current Street Address
Raleigh
City
Fax Number
NC 27615
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:
Chip Goforth [e-mail]
Name of Registered Agent
2240 Sage Valley Drive
Current Mailing Address
Graniteville Sc
City
State
Telephone [phone]
29829
Zip
E-mail Address
2240 Sage Valley Drive
Current Street Address
Graniteville Sc
City
Fax Number N/A
29829
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.
WTC of Tabor City, LLC - Chip Goforth
Type or print 77me
Signature
Member
Title or Authority
(.•Z-ZoZ'L-
Date
I, cr / E —,a Notary Public of the County of
State of North Carolina, hereby certify that 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 2 day of JAJ f- , 20 02-;2-
Seal
Notary
My commission expires Z 7 gofo
EDonna F. Humble uth Carolina
Public, Staff MMaay 27, 2030