HomeMy WebLinkAboutNCC230110_FRO Submitted_20230113FINANCIAL 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 NIA in the blank.)
Part A.
1
Project Name Dollar General - Mocksville
2. Location of land -disturbing activity: County Day1e City or Township Mocksville
Highway/Street TBD Hwy 64 Latitude(decimal degreea35.883505 Longitude(decimal degraes)-80.150767
3. Approximate date land -disturbing activity will commence: December 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.15 acres
6. Amount of fee enclosed: $ 600.00 . 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 Ll Enclosed iJ No [
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name doe Strickland E-mail Address itrickland@teramore.net
Phone: Office # Mobile # 704-224-7364
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Teramore Development, LLC
Name
PO Box 6460
Current Mailing Address
Thomasville GA
City State
10. Deed Book No. 1233
Phone: Office # Mobile #
165 Big Star Drive
Current Street Address
31757 Thomasville GA
Zip City
Page No. 370
State
31758
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).
Teramore Development, LLC
Company Name
214 Klumac Road Suite 101
Current Mailing Address
Salisbury NC 28144
City State Zip
Phone: Office #
jstrickland@teramore.net
E-mail Address
214 Klumac Road Suite 101
Current Street Address
Salisbury NC 28144
City State Zip
Mobile # 704-224-7364
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:
Joe Strickland
jstrickland@teramore.net
Name of Registered Agent
E-mail Address
214 Klumac Road Suite 101
214 Klumac Road Suite 101
Current Mailing Address
Current Street Address
Salisbury NC
28144 Salisbury NC 28144
City State
Zip City State Zip
Phone: Office # 704-224-7364
Mobile # 704-224-7364
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 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.
y�
Joe Stri kland Agent _
Type o print name T Title or Authority
re
I /J,*A/T)f U R
Date
L44?4,y _, a Notary Public of the County of 4 �✓� /u
State of North Carolina, hereby certify that I U r ST /Z z Ccc L-4NO
before me this day and being duly sworn acknowledged that the abov o
Witness my hand and notarial seal, this zZW4day of A d V
DANIIEL R. ALMAZAN
NOTARY PUBLIC
Rowan County, North Carolina
.Ay Commission Expires June 28.2027
i 19
Notary
appeared personally
was executed by him/her.
20 Z'Z
My commission expires IT UNF Z T 1 2 Q 'Z 7
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 all landowners.
Name
Phone: Office # Mobile #
PO Box 1724
209 Kennen Krest
Current Mailing Address
Current Street Address
Clemmon NC 27012
Mocksville NC 27028
City
State
Zip
City State Zip
Deed Book No. 639
Page No. 768 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.