NCC223611_FRO Submitted_20221024

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. Discount Tire Store - Concord NC
1. Project Name
2. Location of land -disturbing activity: County Carrabus City or Township Concord
Highway/Street Concord Parkway N Latitude 35.442181 Longitude -80.607312
3. Approximate date land -disturbing activity will commence: 07/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):1.84+/- Acres
6. Amount of fee enclosed: $130.00 . The application fee of $65.00 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 Daniel Nelms E-mail Address [e-mail]
Telephone [phone] cell # NA Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Metroland LP 717-757-4036 NA
Name Telephone Fax Number
2498 E Market St 2498 E Market St
Current Mailing Address
York, PA 17402
City
State Zip
10. Deed Book No.11317
Page No. 70
Current Street Address
York, PA 17402
City
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.
Halle Properties LLC, Discount Tire of North Carolina [e-mail]
Name
20225 N Scottsdale Road
Current Mailing Address
Scottsdale AZ
City State
Telephone[phone]
E-mail Address
20225 N Scottsdale Road
Current Street Address
85255 Scottsdale AZ 85255
Zip
City
State
Fax Number(480)-606-4370
Zip

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:
NA NA
Name E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Telephone NA Fax Number NA
(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:
Danielle Faust, Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Ave. STE 550 2626 Glenwood Ave. STE 550
Current Mailing Address
Raleigh, NC 27608
City State
Telephone [phone]
Current Street Address
Raleigh, NC 27608
Zip City
Fax Number NA
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 attomey-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.
Matthew Johnson
T pe or print na e
Signature
1, Donna M Warner
Agent
Title or Authority
02-�
Date
a Notary Public of the County of Maricopa
Arizona
State of I+Kelf W4X* hereby certify that Matthew Johnson 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
DONNA M WARNER
Notary Public
tularlcopa County, Arizon9
Comm. Expires 04.06-24
Commission No. 581521
day of E4c h E- , 20
Notary
My commission expires 4/6/2024