NCC222694_FRO Submitted_20220726

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... Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
R Financial Responsibility/Ownership Farm.
No .person. shall iii.itiate .any,latid=disturbing activity covered Eay Section .G: of the Mecklenburg
County, Mint 1401 or -Davidson Sedintentation and Erosion ControlOrdinances prior to
Completing And Ming this form with. M.. ecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept air}+ Notices
of Violation; 6r related: documents for any non-compliance with the aUove Ordinances. If tire
financially resspollsible party is
.out of State; a North Carolina agent bust be assignbd.
Please. Type or Print
PART A
I. Project Wliore laird --disturbing activity is to lie undertakctr: Havant Health Matthews Medical.
Center Tower Expansion
2. Address of land-dis4irbing activity; 1500 Matthews Township Parkway
Matthews; NC.28105
I Approximate date laird -disturbing activity.�-vill commence, 'tuna.
0
5..
G
Manih
Ilu use o`[`development (Residential. Commercial, in..dListrial, cte::):. lioSRlaE
Approx:imato:.acreage.:.of land to be dis..iurbedi or uncovered; 7.2. acres
`fatal siteacreage:.42.'i 3.
:1: 202.2
Day Year
T Landowners.ofrecord (tisc blank pages to list additional owners as necessary):.
owner 41 Name: Novant Health, Inc.
Address: PO Box 33549
Charlotte, NC 28233
Telephone: [phone] lax:
Email Address_ [e-mail]
Owner.#2 Hamer
Address:
Telephone:
Email Address:
C'a)L_.
S. Indicate Book and.Page where the deed or'instrument is filed (use Blank pages to. l st
additional. deeds or ir�struirrents as.:necessary}:
Book. 6088 loge 949
Book
page
Book Page.
Boole Page
(continue on.. back or.separate pages: as .necessary).
l.'omt k Lm5ed i2=266

Continue Financial ResponsihilitylOwnership Farm
PART B%
L Person{s} or fire- (s) rinancialty.responsib.le'for this.land-d'isturbiiig:activ ty
Person or Fit•tl,: Noyant Health, Inc.
Address: P Box 33549
Charlotte; NC 282.3.3
Telephone: 704-316=435.1:
Ema l Address:: [e-mail]
Fax.
2.. North.Camlina agent for the person or firm who 'is::f nan�ialIy iesponsi.ble:
Person or Firm:.
Address:
`1`'elephone-;
Email Address:
Fax-
3'. The. above information is true and correct to. the hest of my knowledge and belief at.id was.
provided by M.0 while` under Oath. ( Fhis forrn rhost be `sighed by the financially responsible
person if an individual or by an officer, director; partner,. attol•ney-in-fact; or o#her person
with`autliorityto execute instrun-ients for the frtancially responsibleconipatiy or entity; it not
an0. 0 individual,)
OL ` �. S r
Printed Name Title
Signature Date
'a Notary .Public of the
County of. M. � State of A Cwm ZZ" -D, , hereby:
certify brat 6n C, personally appeared
before ine this day .arid under:oath acknowledged that this farm was executed by him/her.
Witness my liand. and notarial. seat, this. day of . A-Q--' 4.. x 20
No tary..SiPature: �azk" JJh Lx"-7
My. Com1iiissio11. expires.:..__..._.- .: f Yil �?� [q- -
lCathleen inn. Wilson
NOTARY PUBLIC ; cklenburg.Cowity.Land [Jse;and. CnVironniental Services Agency
Rowan County C4SuttiG Ave:
North .C.atolina.
tiny C.Dmmf ssim Expires December 14 202T i Charlotte, NC 282H-m5n!
P€ioue (080.) 314-t3234