NCC230606_FRO Submitted_20230316

Check if this project is ARPA-funded ❑
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. including any
activity under a common plan of development of this size as covered by the NCG01 permit. 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 address or phone
number is unavailable. place N/A in the blank.)
Part A.
1
Project Name Bonwood Storm Drainage Improvement Project
"If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Hi hwa /Street Chadsford Place Latitude, azo�ees, 35.1822-80.8141
g y Longitude dz�ma� dzy�zzs.
3. Approximate date land -disturbing activity will commence: 03/20/2023
4. Purpose of development (residential. commercial, industrial. institutional, etc.): Municipal Drainge
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.0
6. Amount of fee enclosed: S 200 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is S900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Carl Schaefer E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners).
N/A
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

Part B.
1. Company(ieo) who are financially responsible for the land -disturbing activity (Provide acomprehensive fist
ofall responsible parties unaccompanied page,)If the company isesole proprietorship u/ifthe landowmerls/is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Company Name
600 East 4th Street
Current Mailing Address
Charlotte NC 28202
City State Zip
�D�-���-�[3��
Phone: Office # '"�" "�^= "�="
E-mail Address
600 East 4th Street
Current Street Address
Charlotte NC 28202
City State Zip
Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and toconduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Offioe#
Mobile #
Name nfIndividual hoContact (if Registered Agent is aoompany)
(b) If the Financially Responsible Party
is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name ofRegistered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Dffice#
Mobile #
Name ofIndividual |oContact (if Registered Agent ioacompany)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Mike Davis, PE
Type or print name
Signature
Director of Storm Water Services
Title or Authority
3/.Z,�2 O
Date
I, aw a Notary Public of the County of [?U kyl
State of North Carolina, hereby certify that i Kit VGA l appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of k Nt6l 20 )
,1KE
'Notary
'STAR`
My commission expires) �-1
A L ,
+,,, (1B `` ,,

Continued from 8enns 9 & /D /n Part A of the Financial ResponsibilitylOwnership FOnrn for multiple
owners, Attach copies of this page esneeded tolist all landowners.
Landowner 2 of Record:
Nome Phone: Dffioe# Mobi|e#���������
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide e copy of the most current deed.
Landowner 3 of Record:
Name Phone: Offioe# TobUe#
Current Mailing Address Current Street Address
City State 2]p City State Zip
Deed Book No. Page No. Provide acopy ofthe most current deed.
Landowner 4ofRecord:
Nome Phone: Offioe# K8ubi|e#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. PageNo. Provide ocopy ofthe most current deed.
Landowner 5ofRecord:
MailingPhone: Office# Mobile #
Current
Address Current Street Address
City State Zip City
Deed Book No. PageNo._____
Provide a copy of the most current deed.
State Zip

Company 2Name
Current Mailing Address
City State
Phone: Office#
Company 3Name
Current Mailing Address
City
Phone: Offioe#
Company 4Name
Current Mailing Address
E-mail Address
Current Street Address
�ip Cih/ State Zip
Mobile #
E-mail Address
Current Street Address
State Zip City State
yWobi|e#
E-mail Address
Current Street Address
Chy State Zip City State Zip
Phone: Offiue# YNobi|o#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #