NCC224000_FRO Submitted_20221205

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. STOWE REGIONAL WATER RESOURCE RECOVERY FACILITY
1. Project Name
2. Location of land -disturbing activity: Count Mecklenburg City or TownshipCharlotte
Highway/Street Hawfield Road Latitude35.279667 Longitude-81.005727
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):39.5 acres
6. Amount of fee enclosed: $ 2 535+100=2635 The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name N icole Bartlett E-mail Address [e-mail]
Telephone[phone] cell# Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Charlotte Water
704-391-5126 N/A
Name
Telephone Fax Number
5100 Brookshire Blvd
5100 Brookshire Blvd
Current Mailing Address
Current Street Address
Charlotte NC
28216 Charlotte NC 28216
City State
Zip City State Zip
10. Deed Book No.28400
Page No.380-381 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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Charlotte Water
[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 State Zip
Telephone[phone]
Fax Number704-398-9180

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A Ng N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
N/A
E-mail Address
N/A
Current Street Address
N/A N/A N/A N/A N/A
City State Zip
Telephone N/A
City State Zip
Fax Number N/A
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.
C. Wilson Chief Engineer
print name
SiMalture
Title or Authority
DateT�
I, '��a , wi�,1t `� a Notary Public of the County of
State of North Carolina, hereby certify that 300 qh G W tI( `�Oh 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 f day of 0 CkIDW 20 11
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