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HomeMy WebLinkAboutNCC231232_FRO Submitted_20230427 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name 146 Commerce Drive 2. Location of land-disturbing activity: County Davie City or Township Bermuda Run Highway/Street 146 Commerce Drive Latitude(decimai degrees) 36.00816 tong ltude(decimal degrees)-80.4 3448 1 3. Approximate date land-disturbing activity will commence: February 1, 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.). Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.24 6. Amount of fee enclosed: $ 400 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 ® No ❑ 8 Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name P E-mail Address Phillip Cranmer peranmer@highlinesp.com Phone: Office# 404-964-9122 Mobile# 9. Landowner(s) of Record (attach accompanied page to list additional owners): STOR ADVNC COMMERCE LLC 678-619-5412 404-643-8245 Name Phone: Office# Mobile# 2033 Monroe Dr 2033 Monroe Dr Current Mailing Address Current Street Address Atlanta, GA 30324-4830 Atlanta, GA 30324-4830 City State Zip City State Zip 10. Deed Book No. 1206 Page No. 0866 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). STOR ADVNC COMMERCE LLC jberry@highlinesp.com Company Name E-mail Address 160 Mine Lake Court, Suite 200 146 Commerce Drive Current Mailing Address Current Street Address Raleigh, NC 27615 Advance, NC 27006 City State Zip City State Zip Phone: Office# 678-619-5412 Mobile# 404-643-8245 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: 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) (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: CT Corporation System Name of Registered Agent E-mail Address 160 Mine Lake Ct Suite 200 160 Mine Lake Ct Suite 200 Current Mailing Address Current Street Address Raleigh, NC 27615 Raleigh, NC 27615 City State Zip City State Zip Phone: Office# 919-944-4780 Mobile# Erin Sanders 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. James A. B 6r President Type or :pr n na Title or Au horit I E �r3 Signatu a Date I, jaA. Casa , a Notary Public of the County of Gebb Cto12Gi (} �p State of J hereby certify that Rms s a appeared personally before me this day and being duly sworn acknowledged that the c4ove form was executed by him/her. Witness my hand and notarial seal, this day of V�a-wLx� 20 .2-3 Notary Seal My commission expires a-06•2-6 r� W 11111111,! ��.� 4� CA V,qG, • Q:o }� N• d �;9 N �� (r 0 fi 2p••f.� �t I����'UNr 1 ti0%��,,