NCC240859_FRO Submitted_20240327

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Wawa Halstead and Eringhaus
1. Project Name g
2. Location of land disturbing activity County Pasquotank City or Township Elizabeth City
Highway/Street Halstead BLVD Latitude 36.29389 Longitude-76.245595
3. Approximate date land-disturbing activity will commence March 1 , 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.)T Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.20
6. Amount of fee enclosed: S 300 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Will Gautier E-mail Address [e-mail]
Telephone [phone] Cell# 252-217-5512 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Shuang Mu, LLC (Hang Huang) 646-283-7680
Name Telephone Fax Number
121 Pineview Drive 121 Pineview Drive
Current Mailing Address Current Street Address
Elizabeth City, NC 27909 Elizabeth City, NC 27909
City State Zip City State Zip
10. Deed Book No 1 343 Page No 187 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.
A.R. Chesson Construction Company, Inc. [e-mail]
Name E-mail Address
P.O. Box 1147 315 W. Main St.
Current Mailing Address Current Street Address I -1-1Williamston, NC 27892 Williamston, NC 27892 C l IN 7
City State Zip City State ZIP AIR Q
Telephone [phone] Fax Number NIA

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:
Al R. Chesson, Jr. [e-mail]
Name E-mail Address
315 W. Main St. 315 W. Main St.
Current Mailing Address Current Street Address
Williamston, NC 27892 Williamston, NC 27892
City State Zip City State Zip
Telephone [phone] Fax Number N/A
(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 Fax Number
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.
Al R. Chesson, Jr. President
Type r rat-��ec��� Title or Authority
/4 fC/ 444 7\AD 2/27/24
Signature Date
I, I)tt i,.I,,h< Ns-if , a Notary Public of the County of 11I,,il,rn,-/ ,.,
State of North Carolina, hereby certify that A l t . [ '.{ ,r , -, appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand an l��+iseal, this 2 2 day of e �)r,,,,,, �� , 20 2A
le4- 14o TA fi)... -c..\..\''.:::. i' t,1A,t . 6
,_/„... .- ',..h4---, _t 1 1
MY SNoary
n g iL, � I . IS$10N EXPrnEs
U `t� ?c'1 c,) My commission expires q - , - z v Z
L1 MAR 04 2U2y lI i'VBt_tC �?�
/',/SON COV �``��.
annuili
By