NCC232916_FRO Submitted_20231017

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 NameCircle K - NTI NC55 Kennebec - Angier NC
'If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
Angier
2. Location of land-disturbing activity: CountyWake City or Township
35.537144 -78.747133
Kennebec Church Rd&NC 55 Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 04/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
Commercial
5.00
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed: $500 . 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 ❑ Enclosed El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Dennis Patterson E-mail Address [e-mail]
[phone]
Phone: Office#
Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Circle K Stores Inc.
Name
Phone: Office# Mobile#
1100 Situs Court, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27606-4295
City
State Zip City State Zip
19245 Pa a No.461-464
10. Deed Book No. g 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).
Circle K Stores Inc.
Company Name E-mail Address
1100 Situs Court, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27606-4295
City State Zip City State Zip
Phone: Office# [phone] 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:
Meredith W. Rice, Jr. [e-mail]
Name of Registered Agent E-mail Address
1100 Situs Court, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27606-4295
City State Zip City State Zip
Phone: Office# [phone] 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.
Meredith W. Rice, Jr. Vice President
Type or print name Title or Authority
1
Signature Date
I Pok;,-; F , a Notary Public of the County of Jb STol..\
'1 t t X ]-r• appeared personally
State of North Carolina,hereby certify that I'l'1e,�ed I{-l� 'w•
before me this day and being duly sworn acknowledged that the/ above form was executed by him/her.
711
Witness my hand and notarial seal,this
/oo day of V 1E , 20.3
ROBIN F. ALFORD
Notary Public, North Carolina Not ry
Johnston County
My Cmixiission Expires _ oa.�
April 23,202i3 My commission expires GZ 3

Continued from Items 9 & 10 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 State Zip
Phone: Office# Mobile#