NCC233744_FRO Submitted_20231221

Check if this project is ARPA-funded ❑
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 Name Triangle Stop Mills River - Proposed Expansion
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Henderson City or Township Mills River
Highway/Street NC 280 Latltude(decimai degrees)35.3884 Longitude(decimai degrees)-82.5660
3. Approximate date land-disturbing activity will commence:July 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .07 acres
6. Amount of fee enclosed: $200'00 . 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 D Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Hall Waddell E-mail Address [e-mail]
Phone: Office# 828-692-0246 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J.H. Reaben Oil and Supply Co. 828-692-0246 828-577-0067
Name Phone: Office# Mobile#
4499 Boylston Highway PO Box 629
Current Mailing Address Current Street Address
Mills River, NC 28759 Hendersonville, NC 28793
City State Zip City State Zip
10. Deed Book No. 640 Page No. 1 17 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).
J.H. Reaben Oil and Supply Company, Inc. [e-mail]
Company Name E-mail Address
PO Box 629 751 Ashe Street
Current Mailing Address Current Street Address
Hendersonville, NC 28792 Hendersonville, NC 28792
City State Zip City State Zip
Phone: Office# 828-692-0246 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:
J. Hall Waddell [e-mail]
Name of Registered Agent E-mail Address
PO Box 629 751 Ashe Street
Current Mailing Address Current Street Address
Hendersonville, NC 28792 Hendersonville, NC 28792
City State Zip City State Zip
Phone: Office# 828-692-0246 Mobile# [phone]
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.
J. Hall Waddell President
Type(or prin na a (� Title or Authority
po
-9)-14,/ .S.-/- 1-)>
Signat�e Date
I, M• SC1 p�9e.{-t , a Notary Public of the County of )441WooL
State of North Carolina, hereby certify that 7. kAa-kk \I&Irkik 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 02• day of Ma`{ , 20 23
• /V 4(�
Nota y
Seal
My commission expires ill i 1 Zo7,3

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:
Reaben Hwy 64, LLC 828-692-0246 828-577-0067
Name Phone: Office# Mobile#
4195 Haywood Road 751 Ashe Street
Current Mailing Address Current Street Address
Mills River, NC 28759 Hendersonville, NC 28792
City State Zip City State Zip
Deed Book No.3159 Page No.0497 Provide a copy of the most current deed.
Landowner 3 of Record:
Reaben Hwy 64, LLC 828-692-0246 828-577-0067
Name Phone: Office# Mobile#
4195 Haywood Road 751 Ashe Street
Current Mailing Address Current Street Address
Mills River, NC 28759 Hendersonville, NC 28792
City State Zip City State Zip
Deed Book No.3159 Page No.0497 Provide a copy of the most current deed.
Landowner 4 of Record:
J. H. Reaben Oil and Supply Company, Inc. 828-692-0246 828-577-0064
Name Phone: Office# Mobile#
49 Moody Park Dr. 751 Ashe Street
Current Mailing Address Current Street Address
Mills River, NC 28759 Hendersonville, NC 28792
City State Zip City State Zip
Deed Book No.3159 Page No.0493 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.

Land Owners Consent -- Reaben Hwy 64, LLC
Date: -
Mr.Stanley Aiken,P.E.
Regional Engineer
Land Quality Section
North Carolina Department of Energy,Mineral and Land Resources
2090 US70 Highway
Swannanoa,NC 28778-8211
Re:Triangle Stop Mills River—Proposed Expansion
Dear Mr.Aiken:
We hereby authorize J.H.Reaben Oil and Supply Company,Inc.to be the financially responsible party and to submit an
erosion and sediment control plan and to conduct the anticipated land disturbing activities as described in WGIA
Engineering drawings as being approximately 2.20 acres+J-on a portion of parcels numbers:9631-75-2383 and 9631-
17-4218 documented at the Henderson County Courthouse Land Records Office located at 85 Grove Street,
Hendersonville,NC 28792.
Signed by property owner(s},
9J41(
(„),:,,s7,07?
I.
Lan Owner of IN-cordl
J.Hall Waddell,Manager
Reaben Hwy 64,LLC
Signed zN=rJ��
I, 'A. g211- ,a Notary Public for then State of_ YWQo. __,County of
JJDCk C.gtb�; ,do hereby certify that S. Np�,1�� J.Ae.4( personally appeared
before me this 6 L day of MaW ,2013,and acknowledge the due
execution of the for oin rmission form. Witness mylhand and official seal,
SEAL
My commission expires tiV-44122.2.