NCC222696_FRO Submitted_20220727

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. ModWash - LocustNC
,
1. Project Name c
2. Location of land -disturbing activity: County `Manly City or Township Locust
Highway/Street NC 86 South Latitude 35.2554 N Longitude 80.4567 W
3. Approximate date land -disturbing activity will commence: 8/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.30
6. Amount of fee enclosed: $ 700.00 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 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 $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Thomas Hoopes E-mail [e-mail]
Telephone [phone]
Cell # 407-492-6934 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
WRS Centers I, LLC n/a n/a
Name Telephone Fax Number
550 Long Point n/a
Current Mailing Address Current Street Address
Mt. Pleasant, SC 29464 n/a
City
State Zip
10. Deed Book No. 1 476
Page No.
City
594
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.
Hutton Locust NC ST, LLC
Name
736 Cherry St
Current Mailing Address
[e-mail]
E-mail Address
736 Cherry St
Current Street Address
Chattanooga, TN 27402 Chattanooga, TN 27402
City State Zip City State Zip
Telephone [phone]
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:
Corporation Service Company
Name
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Raleigh, NC 27608
City State
Telepho
[e-mail]
E-mail Address
2626 Glenwood Avenue, Suite 550
Current Street Address
Raleigh, NC 27608
Zip 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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
City State
Telephon
NIA
E-mail Address
NIA
Current Street Address
NIA
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:
McAdams [e-mail]
Engineering Firm or other consultant E-mail Address
Caleb Robinson, RLA 919-287-0728
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.
Benjamin P. Harper
Authorized Officer
Type or print name Title or Authority
03/10/2022
Signat Rate
I, 7N r 1 l/lA C 1. V a Notary Public of the County of-#�(/l�,�/Q���
Slate of North Carolina, hereby certify that 1 appeared personally
before me this day and being duly sworn acknowl dged that the i'above form wbs executed by him.
Witness my hand and notarial seal, this day of 1 20
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