NCC231467_FRO Submitted_20230519

(r- p SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
NA, 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
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 has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A
1. Project Name Walmart 4274- Denver, NC
2. Location of land-disturbing activity: Latitude 35.452569 Longitude 81.001903
Parcel Identification Number(PIN)4602450254 Watershed Area
Highway/Street Address 7131 Highway NC-73- Denver, NC
3. Approximate date land-disturbing activity will commence:05.01.2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):0.79
6. Amount of fee enclosed: $200.00 .The Standard Permitting application fee of$200.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example: 9 acres total 51,800). The Express
Permitting application fee is a dual charge. The normal fee of$200.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount. In addition,the Express Permitting supplement is S250.00 per acre up to eight
acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total$3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed x
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chris Lee E-mail Address [e-mail]
placeservicesinc.com
Telephone [phone] Cell# 678.478.1734 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Walmart Real Estate Business Trust 479-204-0201
Name Telephone Fax Number
PO Box 8050 702 SW 8th Street
Current Mailing Address Current Street Address
Bentonville AR 72712 Bentonville AR 72712
City State Zip City State Zip
10. Deed Book No.2041 Page No.653 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable: (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

CR� k..,!_. SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
7 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
Part B
1. Person(s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive
list of all responsible parties on an attached sheet):
Walmart Real Estate Business Trust [e-mail]
Name E-mail Address
PO Box 8050 702 SW 8th Street
Current Mailing Address Current Street Address
Bentonville AR 72712 Bentonville AR 72712
City State Zip City State Zip
Telephone [phone] Fax Number
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:
CT Corporation System
Name E-mail Address
160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate 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:
Atwell, LLC [e-mail]
Engineering Firm or other consultant E-mail Address
1800 Parkway Place - Suite 700 Marietta, GA 30067
Current Mailing Address City State Zip
Brian Pelham 770.733.7905
Individual contact person(type or print) Telephone Fax Number

: ''''a , SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
R«n" 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
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FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d)Contractors and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity:
PSI - Place Services, INC
Name of Person or Firm Name of Person or Firm
201 Gateway Drive
Current Mailing Address Current Street Address
Canton GA 30115
City State Zip City State Zip
Chris Lee - Project Manager
Individual contact person (type or print) Individual contact person (type or print)
678.478.1734
Telephone Telephone
Fax Number Fax Number
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 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 Person). I agree to provide corrected information should there by any change in the information provided
herein and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or related to this permit.
J0Hil C SAU- FR05FL7 "14iii/46iiW-4/7
Type or print name Title or Authority
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Signature Date
I, S\I -L-Jr Rd • 0 i .-t+ , a Notary Public of the County of 3tr1 k07 rl
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State of North-£are4+44a, hereby certify that TD hh ( -5 2 re-S 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 9 day of lk-ka..L ,20 '2
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,«,,nniii,,,a Notary--- _
`� �. •.�2 - My commission expires S • z1• 2-03,-
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