NCC223355_FRO Submitted_20220927

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Naine DC Expansion/Shweliness Center
2. Location of land -disturbing activity: CountyAlamance City or Township_ Burlington
Highway/Street White's Kennel Rd Latitude�de.imal degrees) 3$.0475 Longltude(dacimaidegrees) 79_4454.
3. Approximate date land -disturbing activity will commence. August 2022 A
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.08
6. Amount of fee enclosed: $ 800.00 . 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed © No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeff Masters E-mail Address [e-mail]
Phone: Office # 801-428-1131
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Altoona Development Blair County Corp 814-944-6113
Name
13900 industrial Park Drive
Current Mailing Address
Altoona, PA 16602
Phone: Office # Mobile #
3900 Industrial Park Drive
Current Street Address
Altoona, PA 16602
City State Zip City State
Zip
10. Deed Book Na. 3172 Page Na. 300 Provide a copy of the most current deed.

Part B.
I. 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 sore proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party{ias).
The Dennis Group, LLC
Company Name
1537 Main Street
Current Mailing Address
Springfield, MA 01103
City State Zi
Phone: Office # 413-787-1785
[e-mail]
E-mail Address
1537 Main Street
Current Street Address
_ Springfield, MA01103
p City State
Mobile #
Zip
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:
Richard J Smith [e-mail]
Name of Registered Agent E-mail Address
1537 Main Street _ 1537 Main Street
Current Mailing Address Current Street Address
Springfield, MA 01103 _ Springfield, MA 01103
City State Zip City State Zip
Phone: Office # _ _ _ 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
City State
Phone: Office #
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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 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.
Richard J. Smith Manager
Type or Tin arse Title or Authority
8/19/22
Sig atur Date
a Notary Public of the County of
D°+vis
u� R������ 5�,
State of North Cartalir�a, hereby certify that 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 day of �� � _ 2011
9
4 KELLI E CHILES Notary
NOTARY PUBLIC • STATE OF UTAH
i' f0tB016mm, Exp. 09/23/2025
Commission # 720549 My commission expires

August 19, 2022
Sheetz Inc
1737 White's Kennel Road
Burlington, NC
The Dennis Group, LLC
1537 Main Street
Springfield, MA 01103
RE: DC Expansion/Shwellness Center Project
Project ID: ALAMA-2022-066
Landowner Building Agreement
To Whom It May Concern:
Through this letter, the undersigned on behalf of Sheetz gives the Dennis Group authority to
pursue plan approvals for erosion and sediment control plans for the DC Expansion/Shwellness
Center project, located at 1737 White's Kennel Road in Alamance County. The undersigned
also gives permission for the Dennis Group to perform construction on this property.
Please contact the undersigned at 919-632-7542 or mmashbur;6)sheetz.com
Sincerely,
/" Iwlgl`
Michael Mashburn
Burlington Operations Manager
Sheetz