NCC220277_FRO Submitted_20220113

NOUR
Mecklenburg County Soil Erosion and
E ' Sedimentation Control Ordinance
° GA Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. if the
financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken: IPEX New Production Buildi
2. Address of land -disturbing activity: 10320 Rodney Street, Pineville, NC 28134
3. Approximate date land -disturbing activity will commence: November 01 2021
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Industrial/Manufacturing
5. Approximate acreage of land to be disturbed or uncovered: 9.1 acres
6. Total site acreage: +/- 7.9 acres
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Pierre Coulombe
Address: 3 Place du Commerce, bureau 101, Ile des Soeurs, Verdun, QC H3E 1 H7 Canada
Telephone: [phone] A 20308 Fax:
Email Address: [e-mail]
Owner #2 Name: Martin Robitaille
Address: 3 Place du Commerce, bureau 101, Ile des Soeurs, Verdun, QC H3E 1 H7 Canada
Telephone: [phone] A 20336 Fax:
Email Address: [e-mail]
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 11200 Page 527 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART S
1. Person(s) or firm(s) financially responsible for this land -disturbing activity_
Person or Firm: Pierre Coulombe
Address: 3 Place du Commerce, bureau 101, lie des Soeurs, Verdun, QC H3E 1 H7 Canada
Telephone: 514 7E9-3445 xt. 20308 Fax:
Email Address: pierre.coulombeC&ipexna.com
2. North Carolina agent for the person or firth who is financially responsible:
Person or Firm: IPEx USA, I_LC - Shawn White
Address: 10100 Rodney Street, Pineville, NC 28134
Telephone: [phone] Xt. 50209 Fax:
Email Address: shawn.white(�iexam_e_rica.com
3. The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath. (This form must be signed by the financially responsible
person if an individual or by an officer, director, partner, attorney -in -fact, or other person
with authority to execute instruments for the financially responsible company or entity, if not
an individual.)
Pierre Coulombs VP VP of Engineering
Printed N. UU�s Title
siggature v •' y ''x• Date
�a , a Notary Public of the
County of ^�r►��rl�a State of C�c , hereby
u
certify that Ong A cl kze personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this
Notary Signature: _—
+..
My Commission expires:
day of C-N -sc, YeA
Mecklenburg County Land Use and Environmental Services Agency
2145 5uttle Ave.
Charlotte, NC 28208-5237
Phone [phone]