NCC222935_FRO Submitted_20220906

wL uepartment of
Environmental Quality
Received
FINANCIAL RESPONSIBILITY/OWNERSHIP rORM
SEDIMENTATION POLLUTION CONTROL ACT JUN 2 12022
EXPRESS PERMITTING OPTION ,a4 Winston-Salem
No person may initiate any land -disturbing activity on one or more acres as covered by the ARb0M@ltJjffiWnn
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.
1. Project Name Proposed Family Dollar Store - N. Wilkesboro, NC
2. Location of land -disturbing activity: County Wilkes City or Township North Wilkesboro
Sparta Road 36.182000 N 81.148546 W
Highway/Street LatltUde(decimaldegrees) Long ltUde(decimaldegrees)
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): 1.70
6. Amount of fee enclosed $700.00 . 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 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Trey Perman E-mail [e-mail]
Phone: office # 256-413-0433 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NORTH WILKESBORO, LLC
Name Phone: Office # Mobile #
2425 LUMBLEY ROAD 2425 LUMBLEY ROAD
Current Mailing Address
RAINBOW CITY, AL 35906
City State Zip
10. Deed Book No. 1349 Page No.
Current Street Address
RAINBOW CITY, AL 35906
City
446
State
Zip
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 landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
NORTH WILKESBORO, LLC
Company Name
2425 LUMBLEY ROAD
Current Mailing Address
RAINBOW CITY, AL 35906
City State Zip
Phone: Office # 256-413-0433
[e-mail]
E-mail Address
2425 LUMBLEY ROAD
Current Street Address
RAINBOW CITY, AL 35906
City State Zip
Mobile #
Note: If 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:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(c) 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 comp, y not registered and doing business under a, • assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If 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:
LE&D Professionals, PC
[e-mail]
Engineering firm or other consultant E-mail Address
Ryan Gatewood, PE 434-792-3680
Individual contact person (type or print) Phone: Office # Mobile #
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.
��WA �-� / e rr�cx � � zu,���
Type or print name Title or Authority
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Signatur Date(
6-Pew \)0 c c-Pr , a Notary Public of the County of +O\dCk {\
P05 6'ma'P�,� t
State of . , hereby certify that -;- � v ; 2L appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this d (Y day of 20
GEN,,z— Notary
f
4ATA9/- �,�� ' My commission expires
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