NCC222468_FRO Submitted_20220711

FINANCIAL RESPONSIBILITYIOWNERSHIP 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, it the question is not applicable or the e-mail and/
or fax information unavailable, place NIA in the blank.)
Part A. Willows at Stallings
1. Project Name g
2. Location of land -disturbing activity: County. nion City or Township Stallings
Highway/Street Stevens Mill Rd Latitude35.1062 Longitude-80.6757
3. Approximate date land -disturbing activity will commence: September 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 21.0
6. Amount of fee enclosed: $1365.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Urban Design Partners E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gateway Stallings, LLC [phone] n/a
Name Telephone Fax Number
13860 Ballantyne Corporate Pl. Ste.175 2816 Stevens Mill Road
Current Mailing Address Current Street Address
Charlotte NC 28277 Stallings NC 28104
City State Zip City State Zip
10. Deed Book No.7623 Page No.0730 & 0726 provide a copy of the most current deed.
Part B.
1. Company(les) 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.
Gateway Stallings, LLC [e-mail]
Name E-mail Address
13860 Ballantyne Corporate PI. Ste. 175 2816 Stevens Mill Road
Current Mailing Address Current Street Address
Charlotte NC 28277 Stallings NC 28104
City
State Zip City
Telephone [phone] Fax Numbern/a
State
Zip

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:
nla
Name
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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:
David Ransenburg
Name of Registered Agent
13860 Ballantyne Corporate Pl. Ste. 175
[e-mail]
E-mail Address
2816 Stevens Mill Road
Current Mailing Address Current Street Address
Charlotte NC 28277 Stallings
City
State Zip city
Telephone [phone]
Fax Number
NC 28104
State Zip
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 attomey-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 th1e� information p ovided herein.
e , jp"'"6"
Type or print name a Title or Authority
ture
5-1Z�zoz;z—
Date
I, _ Q rr4aja, 1% , a6cK We- ( I , a Notary Public of the County of I A 0 i D I-)
State of North Carolina, hereby certify that Da. ve A5.-✓t San appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this � hnVday of 6n �, 20 0�-�-
ms ,t Notary
al � z
� My commission expires 1—I