NCC233118_FRO Submitted_20231020

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 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 Proposed Sheetz C-Store and Gas Station
2. Location of land-disturbing activity: County Lee City or Township Sanford
Jefferson Davis HWY 35°2611.94"N 79°13'12.371W
Highway/Street Latitude(decrmaldegrees) Long itude(decfmaldegrees)
3. Approximate date land-disturbing activity will commence: September 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): +/- 2.2 acres
6. Amount of fee enclosed: $300 . 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 0 Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Doug Benoit E-mail Address [e-mail]
Phone: Office# (781 ) 769-5900 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Donald R Simpson 919-770-2104
Name Phone: Office# Mobile#
503 Carthage Street 503 Carthage Street
Current Mailing Address Current Street Address
Sanford NC 27330 Sanford NC 27330
City State Zip City State Zip
10. Deed Book No. 471 Page No, 161 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 landowners)is
an individual(s), the name(s) of the owner(s)may be listed as the financially responsible party(ies).
Arista Sanford LLC [e-mail]
Company Name E-mail Address
450 Station Ave same
Current Mailing Address Current Street Address
South Yarmouth, Ma 02664 same
City State Zip City State Zip
Phone: Office# (781 ) 769-5900 Mobile# [phone]
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:
C T Corporation Systrm [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Suite 200 same
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Phone: Office# [phone] Mobile#
Stephanie Picco
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.
Scott Weymouth Principal
Type or print Ilk Title or Authority
_ , eir,0001 AS/431g.7---
ignature / Date
A A S-t'<.a , a Notary Public of the County of tJvv AIL
rA � 1
ina, hereby certify that , I�C' ' 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 /Pk day of .+-* ( , 20 2 Z-
. . �, 1! —
otary My commission expires A/4 � 9l 44•2

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:
Bradley Dixon McNeill and Joy Chafin [phone]
Name Phone: Office# Mobile#
1186 OVERLAKE AVE 1186 OVERLAKE AVE
Current Mailing Address Current Street Address
FOREST VA 24551 FOREST VA 24551
City State Zip City State Zip
Deed Book No. 32 Page No. 397 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#