NCC222785_FRO Submitted_20220803

Town of
Tol"l, "f oil Soil Erosion & Sedimentation Control Ordinance
NORTH CAPOLINA Financial Res ponsibility/Ownersh i • Form
No person shall initiate any land -disturbing activity as defined in the Town of Huntersville Soil
Erosion and Sedimentation Control Ordinance prior to completing and filing this form with the Town
of Huntersville. The financially responsible party will be on record as the party to receive any
Notices of Violation or related documents related to non-compliance issues with the above
Ordinance. By filing this form, the parties are not relieved from any other permits that may be
required for the Project. If the financially responsible party is out of State, a North Carolina agent
must be assigned.
Please Type or Print
1. Project where land -disturbing activity is to be undertaken: Metrolina Dormitories
14824 Huntersville-Concord Rd, Huntersville NC 28078 (PID 02122102, 02122108, 02122104, 02122105)
2. Address of land -disturbing activity: 14824 Huntersville-Concord Rd, Huntersville NC 28078
3. Approximate date land -disturbing activity will commence: May 1 2022
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential - H-2A
5. Approximate acreage of land to be disturbed or uncovered: 12.52 housing(Dormitories)
6. Total site acreage: 289.54 ac
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: METROLINA GREENHOUSES INC
Address: 16400 HUNTERSVILLE-CONCORD RD HUNTERSVILLE NC 28078
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary)
Book 34068 Page 974 Book Page
Book Page Book Page

1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: METROLINA GREENHOUSES INC
Address: 16400 HUNTERSVILLE-CONCORD RD, HUNTERSVILLE, NC 28078
Telephone: [phone]
Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: METROLINA GREENHOUSES INC (Art VanWingerden)
Address: 16400 HUNTERSVILLE-CONCORD RD, HUNTERSVILLE, NC 28078
Telephone: [phone] Fax:
Email Address: [e-mail]
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 is 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)
Art VanWingerden
Printed NanA,,
Signature
I
I
Owner
Title
&m�� I!
Date
a Notary
Public of the County of 'r��/� 11 , State of AkrWj hereby
certify that 00 Gt1 nzo'-d6n personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this day of Alz A.(/,- , 20.
/., J
Notary Signature: /.Y44�2
�cr.
My Comrni,,z;sion Expires: —
Town of Huntersville
PO Box 664
105 Gilead Rd., Ste 300
Huntersville, NC 28070