NCC240094_FRO Submitted_20240119

Town of j e BNB )
�= �`• Public Works Department
140 Memorial Park Court Southern Pines,NC 28387
Telephone: [phone] Fax:[phone]
(.1outhern Ines
;. 4 ft+ The North Carolina FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
- t:'t South Resort
Internationally Recognized for Pro Midgram Excellence SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity greater than 30,000 sq.ft. as covered by the
Town's Code of Ordinances before this form and an acceptable erosion and sedimentation control
plan have been completed and approved by the Town of Southern Pines and the Land Quality Section,
NC. Department of Environmental Quality. (Please type or print and, if the question is not applicable
or information unavailable, place N/A in the blank.)
Part A.
1. Project Name Discount Tire
2 Location of land-disturbing activity: Highway/Street/Address: 10935 us Hwy 15-501,Southern Pines,NC 28387
Latitude 35.160778 Longitude -79.419944 County Moore City: Southern Pines
3. Approximate date land-disturbing activity will commence July 2023
4. Percent Impervious 69 6
5. Purpose of development (residential, commercial, industrial,institutional,etc.): Commercial
6 Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.6 acres
7. Amount of fee enclosed:$ 450.00
The application fee of$300.00 per acre plus $150.00 for each additional acre, or part thereof, and is
assessed without a ceiling amount. Any substantial revision to a previously approved,active plan is$50
per acre,or part thereof.
8. Has an erosion and sediment control plan been filed? Yes No Enclosed X
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kelly Wagoner E-mail Address kwagoner@fg-inc net
Telephone [phone] _ Cell 770-500-4973 Fax
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Caropines, Inc.,a North Carolina corporation 910-997-2544
Name Telephone Fax Number
1227 Rockingham Road Same as mailing address
Current Mailing Address Current Street Address
Rockingham,NC 28379
City State Zip City State Zip
11. Deed Book No. 5876 Page No. 1 Provide a copy of the most current deed.
Page 3 of 3 1-6-21 B-81

Part B.
1. Person(s),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 maybe listed as the financially responsible party.
Halle Properties,L L.C. construction@discounttire corn
Name E-mail Address
20227 N.Scottsdale Road Same as mailing
Current Mailing Address Current Street Address
Scottsdale,AZ 85255
City State Zip City State Zip
Telephone [phone] Fax
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 [e-mail]
Name E-mail Address
2626 Glenwood Ave. Suite 550 Same as mailing
Current Mailing Address Current Street Address
Raleigh,NC 27608
City State Zip City State Zip
Telephone [phone] Fax
(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:
Matthew Johnson [e-mail]
Name of Registered Agent E-mail Address
20225 N Scottsdale Rd Same as mailing
Current Mailing Address Current Street Address
Scottsdale,AZ 85255
City State Zip City State Zip
Telephone [phone] Fax Number
Page 3 of 3 1-6-21 B-82

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.
Bridget Katuzky AVP.Real Estate
Type or print name Title or Authority
kF(1/ 4'67 5Abe
Signature Date
I, ,C,LA iM ii(Qllfi2 , a Notary Public of the County of 11194 l�cjp4
�i�01'A / / l(plft�t appeared
State of f��iea, hereby certify that �i r a eared
personally before me this day and being duly sworn acknoledged that the Above form was executed by him.
Witness my hand and notarial seal,this A( day of ...J yt./, D64.._ , 20,15
.. DONNA M WARNER C
,,;n,n, = Notary Public
• Maricopa County,Arizona 4032--)1-11jk ‘4.14-4
• My Comm.Expires 04-06-24 Notary
Commission No.581521
SNdt
My commission expires 4� fQ�41
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:December 17,2020
Page 3 of 3 1-6-21 B-83