NCC224220_FRO Submitted_20230104

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. 2251 RIVERSIDE RD.
1. Project Name
2. Location of land -disturbing activity: CountyCLEVELAND City orTownshipSHELBY
Highway/Street RIVERSIDE RD. Latitude35.204737 Longitude-81.661100
3. Approximate date land -disturbing activity will commence: Upon Approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.75 AC
6. Amount of fee enclosed: $ 195+750=$945 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Larissa Coles E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Realty Investors Group, Inc [phone] [phone]
Name Telephone Fax Number
14141 Holly Glade Circle 14141 Holly Glade Circle
Current Mailing Address Current Street Address
Huntersville NC 28078 Huntersville NC 28078
City State Zip City State Zip
10. Deed Book No. 181 1 Page No. 0349 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.
Realty Investors Group, Inc [e-mail]
Name E-mail Address
14141 Holly Glade Circle
Current Mailing Address
Huntersville NC
City
State
Telephone [phone]
14141 Holly Glade Circle
Current Street Address
Huntersville NC 28078
City State Zip
Fax Number [phone]

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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(b) If the Financially Responsible Parry 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant E-mail Address
Individual contact person (type or print) Telephone Fax Number
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.
Tyrone Miller
Type or print name
Sign
awn:cn
Title or Authority
Date
I, 13• 5�0-tT KoAog a Notary Public of the Countyof ram) Y1C o��
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn accknowled ed that the above form was executed by him.
Witness my hand and notarial seal, this 5a-i' day of v5 I-Z 24
B SCOTT ROACH
NQQ Y PUBLIC
RUTHERD COUNTY My commission expires 1.
STATE OF NORTH CAROLINA
MY COMMISSION EXPIRES O4-10-2021