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HomeMy WebLinkAboutNCC230348_FRO Submitted_20230208FINANCIAL 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. Project Name Dollar General - Lexington 2. Location of land -disturbing activity: County Davidson City or Township Lexington Bisecker Road 35.845431 80.254620 Highway/Street Latltude(decimaldegrees) Long ltUde(decimaldegrees) ' 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): 2.04 acres Amount of fee enclosed: $ 300.00 . 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. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 2 No ❑ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Joe Strickland E-mail Address jstrickland@teramore.net Phone: Office # Mobile # 704-224-7364 Landowner(s) of Record (attach accompanied page to list additional owners): Teramore Development, LLC Name Current Mailing Address Thomasville GA 31758 City 704-224-7364 Phone: Office # Mobile # 165 Big Star Drive Current Street Address Thomasville GA 31758 State Zip City State Zip 10. Deed Book No. 2570 Page No. 2329/2344/2353Provide 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). Teramore Development, LLC Company Name 214 Klumac Road Suite 101 Current Mailing Address jtrickland@teramore.net E-mail Address 214 Klumac Road Suite 101 Current Street Address Salisbury NC 28144 Salisbury NC 28144 City State Zip City State Zip Phone: Office # 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 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 Oormation should there be any change in the information provided herein. Joe TvDt print naMe- --- Agent Title or Authority Dat 1, _ 0 AIU2 L A . L /`i ?�4N , a Notary Public of the County of State of North Carolina, hereby certify that 0 S i 2 1-4AJJ appeared personally before me this day and being duly sworn acknowledged that the above fornayvas executed by him/her. Witness my hand and notarial seal, this 2 TKday of s%f ��n 20 Z 2 DANIEL R. ALMAZAN NOTARY PUBLIC Rowan County, North Carolina My Commission Expires June 28,2027 Notary My commission expires (/Nr= Z'K2 o Z 7