HomeMy WebLinkAboutNCC233756_FRO Submitted_20240112 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 NCG01 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 Dollar General Deep Run
*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).
2. Location of land-disturbing activity: County Lenoir City or Township Trent Township
3330 Hwy 11 35.144643 -77.706917
Highway/Street LatitUde(decimaldegrees) LOngitUde(decimaldegrees)
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.70 AC
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 ❑ Enclosed ElNo ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matt Jones E-mail Address mjones@qunity.com
Phone: Office# 919-490-4990 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
James Pratt Ill & Jeanne Pratt
Name Phone: Office# Mobile#
1303 Greenbriar Rd 1303 Greenbriar Rd.
Current Mailing Address Current Street Address
Kinston NC 28501 Kinston NC 28501
City State Zip City State Zip
10. Deed Book No. 769 Page No. 184 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).
Glandon Forest Equity, LLC gbarnes@vanguardpg.com
Company Name E-mail Address
3825 Barrett Drive, Ste. 100 3825 Barrett Drive, Ste. 100
Current Mailing Address Current Street Address
Raleigh, NC 27906-7221 Raleigh, NC 27906-7221
City State Zip City State Zip
Phone: Office# 919.459.2601 Mobile#984.200.9618
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:
George T. Barnes, Jr. gbarnes@vanguardpg.com
Name of Registered Agent E-mail Address
3825 Barrett Dr., Ste. 100 3825 Barrett Dr., Ste. 100
Current Mailing Address Current Street Address
Raleigh, NC 27906-7221 Raleigh, NC 27906-7221
City State Zip City State Zip
Phone: Office# 919.459.2601 Mobile# 984.200.9618
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)
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
3
3
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 1
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
•
r
(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 doingbusiness under an assumed name, attach a copy
p p Y 9
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.
George T. Barnes, Jr. Registered Agent
Type or print na Title or Authority
8/23/23
Signature Date
Tiffani Bylow , a Notary Public of the County of Wake
State of North Carolina, hereby certify that George T. Barnes Jr appeared personally
I 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 23 day of August 2023
' 164/1114—
,• �< ,, Notary
Noia�„P300° = My commission expires 5/4/28
E.
wake Go Q�
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.