NCC240858_FRO Submitted_20240326

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 Chestnut Square Park Phase ll
2 Location of land-disturbing activity: County Union City or Township Indian Trail
Chestnut Parkway 35.081818 -80.666711
Highway/Street LatltUde(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:
4 Purpose of development(residential, commercial, industrial, institutional, etc.): Recreational
5 Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 3.27 Ac
6 Amount of fee enclosed: $ 1 ,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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Todd Huntsinger E-mail [e-mail]
Phone: office# 704-821-5401 ext. 366 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Indian Trail
Name Phone: Office# Mobile#
PO BOX 2430
Current Mailing Address Current Street Address
Indian Trail, NC 28079
City State Zip City State Zip
10. Deed Book No 5468 Page No. I Provide a copy of the most current deed.

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
Deed Book No. Zip
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
Deed Book No. Zip
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
Deed Book No. Zip
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
Deed Book No. Zip
Page No
Provide a copy of the most current deed,

Part B.
1 Company(ies)who are financially responsible for the land-disturbing activity(Provide rt
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 a comprehensive list
Town of Indian Trail A y(es)
Company Name [e-mail]
P.O. Box 2430 Email Address
Current Mailing Address 315 Matthews Indian Trail Road
Iç1anj:raiI, Ncq9d Current Street Address
Indian Trail, NC 28079
State Zip City
Phone: Office# 704-821-5401 ext. 366 State
Zip
Mobile# 7oq _ 2 72. _ v/22 c7
Note: If the Financially Responsible Party is not the owner of the land to be disturbed,
the landowners 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,
include with this form
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 Secretar of S
YState 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 I 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
Phone: Office# Zip
Mobile#
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Phone: Office# Zip
Mobile#
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Phone: Office# Zip
Mobile#
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Phone: Office# Zip
Mobile#

(c) If the Financially Responsible Party is engaging in business under an assumed
which the company is Doing Business As. If the Financially Responsible Part
Partnership, or other company not registered and doing business under an name, give name under
of the Certificate of Assumed Name. assumed name, attach a copy
Y is an individual, General
Company DBA Name
The above information is true and correct to the best of my knowledge me under or (This form must be signed b
bynd was provided
or attorney-in-fact,fact, or if not s individual, by the Financially Responsible Person af an individual(s)
the hisa attorn -i instruments for the Financially icer, director,
corrected informs ion executehould there be anypartner, or registered agent with
e
change in the information rl provided hereine Party). I gfee to provide
T ��� y Type or rint me Title or Authority
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Signature `te /S/✓�za-z3
Date
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State of North Carolina, hereby certify that a Notary Public of the County of /
eared
before me this day and being duly sworn acknowledged that the above//l GJ
foram was executedp by h m/helY
Witness my: , t8
seal, thisJ
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My commission expires "/ —2 -2
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