NCC231728_FRO Submitted_20230606

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 Love's Travel Stop - Store 412
2. Location of land-disturbing activity: County Harnett City or Township Dunn
1-95 & Hodges Chapel 35.3405 78.5568
Highway/Street Latltude(deamai degrees) Longitude)decimal degrees)
3. Approximate date land-disturbing activity will commence: April/May 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):8.8 AC
6. Amount of fee enclosed 2900.00 . 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,after which 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tyler Gill E-mail Address [e-mail]
Phone: Office# 615.862.9944 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Love's Travel Stops & Country Stores, Inc.
Name Phone: Office# Mobile#
PO Box 26210 10601 N Pennsylvania Ave
Current Mailing Address Current Street Address
Oklahoma City, OK 73126 Oklahoma City, OK 73120
City State Zip City State Zip
2764 889-894
10. Deed Book No. Page No. 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).
Love's Travel Stops& Country Stores, Inc. Construction_utilitiespermits©Ioves.com
Company Name E-mail Address
PO Box 26210 10601 N Pennsylvania Ave
Current Mailing Address Current Street Address
Oklahoma City OK 73126 Oklahoma City OK 73120
City State Zip City State Zip
Phone: Office# 4058475452 Mobile#
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:
CT Corporation System chase.waltman©wolterskluwer.com
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Ste 200 160 Mine Lake Ct, Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office#919-944-4780 Mobile #
Chase Waltman
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
(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:
HFA-AE, Ltd. [e-mail]
Engineering firm or other consultant E-mail Address
Rick McGraw, PLA 903-277-8321
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.
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Type or ri t name Title or Authority
10)/al
Sig ture Date
, a Notary Public of the County of 11/1 Cl V1 CY1/1I1
C 1MYVI
State of �t�- �
Ale hereby certify that\,p.✓AIliGI MAYS-✓1 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this j 1 day of k\-y ri--t I . 20 7iY1
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