NCC233577_FRO Submitted_20231205

SOW-
yeruoeRsox "_iY > FINANCIAL RESPONSIBILITY/OWNERSHIP FORM iiEnioEkso
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 Henderson County Site Development Department. (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.)
Sign the original form in BLUE INK.
Part A.
1. Project Name New Sheetz Store - Hendersonville, NC
2. Location of land-disturbing activity: County Henderson City Town of Fletcher
Highway/Street Asheville Hwy Latitude 35.395244 N Longitude 82.504129 W
Property Identification Number(s) PIN's 9974908
3. Approximate date land-disturbing activity will commence: 10/01/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.53
6. Amount of fee enclosed: $2,300.00 . The application fee of$300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a$200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac= $2,900.00).
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 Wes Hall, PE E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
LIV HOLDINGS, LLC
Name Telephone
1 HUNTERS LN 1 HUNTERS LN
Current Mailing Address Current Street Address
HENDERSONVILLE NC 28791 HENDERSONVILLE NC 28791
City State Zip City State Zip
10. Deed Book No.3961 Page No.494 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Sheetz, Inc. [e-mail]
Name E-mail Address
5700 Sixth Avenue 5700 Sixth Avenue
Current Mailing Address Current Street Address
Altoona PA 16602 Altoona PA 16602
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:
Corporation Service Company
Name E-mail Address
2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh NC 27608
City State Zip City State Zip
Telephone
(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
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.
Steven P. Augustine VP of Store Development
Type or print nam Title or Authority
Signature Date
I, \\SS ct (ti1 U,lc o`1e,1— , a Notary Public of the County of 1? 1 Ct. r
State of 'cnns I V i.r-,t U. , hereby certify that 5�i�'i�n ' , At.k., -1-i €,
appeared personaU1r before me this day and being duly sworn acknodged that the above
form was executed by him.
• h
Witness my hand and notarial seal, this 3 day of 4)Lr"c,6 , 20 �3
Commonwealth of Pennsylvania-Notary Seal
Alissa Morgret,Notary Public (M bAori-
Blair
BlairCountyatt 1
My commission expires October 23,2024 Notary
Consigmion number 1384847
Member.Pennsylvania Association of Notaries My commission expires 10"