NCC232232_FRO Submitted_20230822

JOHNSTON COUNTY FINANCIAL 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 Johnston
County Department of Public Utilities. (Please type or print and, 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 Dollar General
2. Location of land-disturbing activity: City or Township Selma—Johnston County
Highway/Street Thanksgiving Fire Road Latitude 35.658586 Longitude-78.309540
3. Approximate date land-disturbing activity will commence: 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):
6. Amount of fee enclosed: $760.00 . The application fee of $380.00 per acre (rounded up to the
next acre) is assessed for the first 10 acres and an additional $125 per acre for each additional acre
(rounded up to the next acre). Individual residential lots plans are$100 per lot.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name George Barnes E-mail Address gbarnesAvanquardpq.com
Telephone [phone] Cell# Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Thanksgiving42, LLC
Name Telephone Fax Number
140 Durham Street
Current Mailing Address Current Street Address
Clayton NC 27520
City State Zip City State Zip
10. Deed Book No. 05781 Page No. 0227
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):
Glandon Forest Equity, LLC gbarnestavanquardpq.com
Name E-mail Address
3825 Barrett Drive, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number 919-459-2604

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
George Barnes gbarnes(c�vanguardpg.com
Name of Registered Agent E-mail Address
3825 Barrett Drive, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number 919-459-2604
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 be any change in the information provided herein.
George Barnes member/manager
Type or print a Title or Authority
Signature Date
I, 3SC Iv►Cox L Jc 4S , a Notary Public of the County of Cycv-A
State of North Carolina, hereby certify that C2Z-OCCAL PDcj.yCUS appeared
personally before me this day and being duly sworn acknoiledged that the above form was executed
by him.
Witness my hand and notarial seal, this 1 day of Fear u.o 9 , 20 7:5
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