NCC230081_FRO Submitted_20230112

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Name Pizza Hut
2. Location of land -disturbing activity: County Halifax City or Township Roanoke Rapids
Premier Blvd. (SR 1751) 36.424623-77.633764
Highway/Street Latltude(decima�de9rees) Longltude(decimaldegrees)
3. Approximate date land -disturbing activity will commence: Winter 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.03
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 m No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJoanne Pate E-mail [e-mail]
Phone: Office # 252-301-2391 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Anz, Ski, Rpl, & Six Mile Invest., LLC N/A
Name Phone: Office # Mobile #
8350 Ivylog Gap Road Same
Current Mailing Address Current Street Address
Young Harris GA 30582 Same
City State Zip City State Zip
10. Deed Book No. 2567 Page No. 393 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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
SIDS Restaurant Group
Company Name
3280 Charles Blvd., Ste. A
Current Mailing Address
Greenville NC 27858
City State Zip
Phone: Office # 2552-301-2391
[e-mail]
E-mail Address
Same
Current Street Address
Same
City State Zip
Mobile # [phone]
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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address
City
Phone: Office #
Current Street Address
State Zip City
Mobile #
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:
N/A
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 company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
R, i7� f —
Compan ame
(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:
Bartlett Engineering & Surveying, PC [e-mail]
Engineering firm or other consultant E-mail Address
Steve Oliverio 252-399-0704 520-850-4665
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.
Joanne Pate Chief Financial Officer
Type r print name Title or Auth rity
mo
ian ture Date
I, I I / , a Notary. Public of the County of JC1 VI VI j
Y'CQ�iy�nn
State of , ereb�r ertify that i�al� appeared personally
before me this day and being duly sworn acknowledged th //the above form was executed by him/her.
Witness my hand and notarial seal, this day of lJ'�� , 20�
y , SHERI M. HARKEY W. 4n k
Notary Public, State 1of 1da N ota
Commission# HH 51ti651 _
My oomm. expires July 11, 2025
My commission expires