NCC223597_FRO Submitted_20221020

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Mallard Creek WRF Trailer and Parking Improvements Phase 2
1. Project Name
E
3
4
Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/street Pilot Road Latitude 35.337173 Longitude-80.700157
Approximate date land -disturbing activity will commence: May 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):�--*V0-6.45 AC
6. Amount of fee enclosed: $560 . 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 Irene Teshamulwa Okioga, PE E-mail Address [e-mail]
Telephone [phone] cell # 704-249-4078 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The City of Charlotte c/o Real Estate Division
Name Telephone Fax Number
600 East 4th Street 12330 North Tryon Street
Current Mailing Address Current Street Address
Charlotte, NC 28202 Charlotte, NC 28262
City State Zip City State Zip
10. Deed Book No. 33253 Page No. 653 Provide a copy of the most current deed.
Part B.
1. Company(ies) 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 orffrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
City of Charlotte [e-mail]
Name E-mail Address
5100 Brookshire Blvd 5100 Brookshire Blvd
Current Mailing Address Current Street Address
Charlotte, NC 28216 Charlotte, NC 28216
City State Zip City MIA State Zip
Telephone [phone] Fax Number

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:
NIA
NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State
Zip City State Zip
Telephone N/A
Fax Number NIA
(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:
NIA
NIA
Name of Registered Agent
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State
Zip City State Zip
Telephone NSA
Fax Number NIA
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 attorney -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 the information provided herein.
Joseph C. Wilson
pript name
Signature
------- g---------------------------- -------------
Chief Engineer
Title or Authority
Date
I, M A yy-e tSon , a Notary Public of the County of MecWnbU_!]
State of North Carolina, hereby certify that 05-p h C.-W)'i15or) 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 l day of MayCh , 20 2 j
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