NCC222851_FRO Submitted_20220816

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
Project Name Wawa - Kill Devil Hills
2. Location of land -disturbing activity: County Dare County City or Township Kill Devil Hills
Highway/Street N Croatan HighwaY Latitude N36 0.2' 09.31" Longitude W75 40' 29.03"
& 4th Street
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 2.99 AC
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes Enclosed ❑ No C7
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Doug Benoit E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Midtown Deveiopment Corp
Name
3200 Pacific Ave, Suite 100
Current Mailing Address
[phone]
Phone: Office # Mobile # _.,.._._
Current Street Address
Virginia Beach VA 23451
City State Zip City
State
Zip
10. Deed Book No_ 164 Page No. 169 Provide a copy of the most current deed

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowners) is
an individual(s), the namets) of the owners) may be listed as the financially responsible party(ies)_
Arista. KDfi LLC
Company Name
450 Station Ave
Current Mailing Address
South Yarmouth MA 02664
City
[e-mail]
Email Address
Current Street Address
State Zip City
State
Phone: Office # [phone] Mobile # [phone]
Zip
Note: It the financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
C i Corporation System
Name of Registered Agent
160 Mine Lake Court
Current Mailing Address
Raleigh NC 27615
City
State Zip
[e-mail]
E-mail Address
Suite 200
Current Street Address
City
Phone: Office # 855 284-8307 Mobile #
Stephanie Picco
Name of Individual to Contact (if Registered Agent Is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

A If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
Of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party), I agree to provide
corrected information should there be any change in the information provided herein.
Greg Botsivales
Principal
Title or Authority
Date
''` '- f , a Notary Public of the County of
i
State of Alo ar iraa, hereby certify that -5 T2k I _appeared personally
before me this day and being duly sworn ackn owl ged ha the above form was executed by him/her,
Witness my hand and notarial seal, this day of 20 'z
z3e'M
Notary
My commission expires �IODI ETTATPi Mr. GIs
GOmmnnweakth of Massachusetts
My Commission Expires
October 21, 2022

Continued from items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list a# landowners,
Landowner 2 of Record:
Name
Phone: Office # Mobil's #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No,
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
city State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed,
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
city State
zip
city State zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item i in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
L-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
State
TIP
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name E-mail Address
Current Mailing Address
City state Zip
Phone: Office #
Current Street Address
City state Zip
Mobile #