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HomeMy WebLinkAboutNCC230584_FRO Submitted_20230307FINANCIAL 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 NIA in the blank.) Part A- 1. Project Name Dollar General - Trenton 2. Location of land -disturbing activity: County Jones City or Township Trenton Twsp. n]G Hwy, 5H 35.06724--77.36611 Highway/Street LatltUde(decimal degrees) LOngltude(declmal degrees 3. Approximate date land -disturbing activity will commence: 01/01 /2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.8 6. Amount of fee enclosed: $ 200.00 . 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 ❑x Enclosed ❑p No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name George Barnes E-mail Address gbarnes@vanguardpg.com Phone: Office # 919.459.2601 Mobile # 919.524.2020 9. Landowner(s) of Record (attach accompanied page to list additional owners): Clyde L. Patterson & Michael D. Eaker 919.258.5538 Name Phone: Office # Mobile # 4271 Leaflet Church Road 4271 Leaflet Church Road Current Mailing Address Broadway, NC 27505 City Slate Current Street Address Broadway, NC 27505 Zip City State Zip 10. Deed Book No. 312 Page No. 647 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 namo(s) of the ownar(s) may be listed as the financially responsible party(ies). Glandon Forest Equity, LLC Company Name 3825 Barrett Drive, Suite 100 Current Mailing Address Raleigh, NC 27609 City State Phone: Office # 919.459.2601 gbarnes@vanguardpg.com E-mail Address 3825 Barrett Drive, Suite 100 Current Street Address Raleigh, NC 27609 Zip City Mobile # 919.524.2020 State 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: Sherri Hepps Name of Registered Agent 3825 Barrett Drive, Suite 100 Current Mailing Address Raleigh, NO 27609 City State Phone: office # 919.459.2600 shepps@vanguardpg.com E-mail Address 3825 Barrett Drive, Suite 100 Current Street Address Raleigh, NO 27609 Zip City . State Zip 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 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. George T. Barnes Type or print n e Signature Manager, Glandon Forest Equity, LLC Title or Authority Date I, QblnU,6:j IA% (jokA V15 , a Notary Public of the County of Vr M"V-1 zr--' State of North Carolina, hereby certify that G?AY ?Ju rus appeared personally before me this day and being duly sworn acknowledgeA that the above form was executed by him/her. Witness my hand and notarial seal, this '12 day of NoVe.x-ykbar , 20 Zit Seal :-�' ,�p,AY = j 0IQ 0 Notary My commission expires ail' OS' 13 Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 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 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. Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. Company 2 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Company 4 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City Phone: Office # Mobile # State Zip