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HomeMy WebLinkAboutNCC232481_FRO Submitted_20230816 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. 1. Project Name Field Operations Zone 2 Facility Vacuum Truck Receiving Station 2. Location of land-disturbing activity: County Mecklenburg City or Township Charlotte Highway/Street_General Commerce Dr Latitude 35° 15' 34" Longitude -80° 46' 07" 3. Approximate date land-disturbing activity will commence: Summer 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.):_ Municipal 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.0 6. Amount of fee enclosed: $ 100 . 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 $900). 7. Has an erosion and sediment control plan been filed? Yes No EnclosedX 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Brian D. Pate E-mail Address brian.pate@_charlottenc.gov Telephone 704-336-1067 Cell # 980-721-0229 Fax# N/A 9. Landowner(s)of Record (attach accompanied page to list additional owners): SEE ATTACHED Name Telephone Fax Number 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 (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. City of Charlotte, Joseph C. Wilson cwilsonci.charlotte.nc.us 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 704.399.2221 Fax Number 704.398.9180 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: 41 \A— .1\111\--- Name -E mail Address 01A--- pr\A--- Current Mailing Address Current Street Address if tA.-- I/(4_, City State Zip City State Zip Telephone ( _---- Fax Number t,FS 1A— (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: A— NIA- Name of Registered gent E-mail Address 9 Current Mailing Addr ss Current Street Address Cit State Zi Cit State Zip Y p Y Telephone f' (r Fax Number fr- 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 Chief Engineer Type 1 pri t name Title or Authority /2//t7 'to Z.-1 ' / Sign a Date I, )(At H "*t, . .�� 4 , a Notary Public of the County of State of North Carolina, hereby certify that �® eh C . 1 h appeared personally before me this day and being duly sw.rn acknowledged that the above form was executed by him. Witness my illila d notarial seal, this tla day of 3 i s , 20 ® +� .� f. /ate . . 1 � otary U Notary \ '67 My commission expires B 1.®®®o,®aG®burg®G®®®®