NCC232906_FRO Submitted_20230927

Check if this project/oARPA-fu [—
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Attach a copy of the Letter of Intent&nFund
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one o/ more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCGU1 pemnit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Seotinn, N.C. Department of Environmental C>uo|ib/. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail oddnaoo or phone
number inunavailable, place N/A inthe blank.)
Part A.
y�h'C�-f'|-4 ���A��z1 (��8iDf�| ��U| | |O'V8�6�tV p|@CE>
1� Pn�aot Name ~'^ '` ^' ' ^ ^ '~~ ' Chapel' Hill University' ^ Place
*If this project involves American Rescue Plan Act(4RfA) funds, list the Project Name urProject
Number(e.g., SRP'D-4RP-0/21) be/ow/ under which you were approved for funding through the
Division of Water Infrastructure (DWI).
0/4 [��2O�f� /��BO8| A'||
2. Location of|and'dioturbing activity: County^~ � City or Township Chapel' Hill
��11 S. ��S�8S Fl/'V8 35S�84 -790250
Highway/Street ^ `~' ^- Drive LaU�ude�m/mu/�m��) � Lungitudamoo/mv/uoomoo> �
3. Approximate date land-disturbing activity will commence: 3/11/24
(��OlDl��C'@|
4. Purpose of development(noeidenUe|, oVmmoroia|, industrial, institutional, etc.): Commercial
'
F��
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 '~~
G. Amount of fee enclosed: $ ~��z0O'�~�O
. The application fee of$1OO.OU per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-oora application fee is $900).
Checks should be addressed toNCDEC>.
7. Has an erosion and sediment control plan been filed? Yee271 Enclosed El No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
���E>Ot ��HFO'SfOD h��Dt8dOl'StOO���f�\CO[OCO[�
Name Brent Edmiston E'mai|Addresa~[e-mail]
' �� ' '
xl0z1-7��-�0OO �J/�
Phone: Ofhue# '~ ' ' �~ ~�~~ Mobile# ' `'' ^
9. Landowner(s)of Record (attach accompanied page to list additional owners):
RRPV UD'ye[S'fy Chapel A||| LP 70/1-377-6730 0/4
Name Phone: 0fhne# Mobile#
127VVWorthington Ave, Suite 290
Current Mailing Address Current Street Address
Charlotte, 0C 28203
City State Zip City State Zip
R�A1 ��7�
10. Deed Book No. �~~ ' Page No. 2 Provide o copy of the most current deed.

Part 13.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied paga]If the company ixa sole proprietorship orif the hendo*nor(s)is
anindividual(s). the namo(s) of the ommer(s) may be listed eu the financially responsible porty(ie4),
Chick-f'|-A, Inc. br2Ot.8r|0U'St[)n@cf2cOrD.C<JOO
Company Name E-mail Address
5200BUff'ngfOn Road 5200BUff'n[]tC}n Road
Current Mailing Address Current Street Address
Atlanta, G& 3M349 Atlanta, GA3O349
City State 3]p City State Zip
z1M�1-7A�'��OOO N/A
Phone: O�ua# '~ ' ' ~~ ~~~~ Mobile '°' `
Note: If the Financially Responsible Party in not the owner nfthe land to be dinturbed, include with this fnnn
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct 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: 0Mioe# Mobile #
Name of Individual to Contact(if Registered Agent inacompany)
(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:
Will Choate VVchC}ate@metcaOEldV'Sor.cO0
Name of Registered Agent E-mail Address
420 OUe8D8 Road, Unit 5 /120 QU88nS ROaH, Unit 5
Current Mailing Address Current Street Address
Charlotte, NC 28207 Charlotte, NC 28207
City 0aha Zip City State Zip
7O/�-77A-1M�1�
Phone: {}��oo# ' � ' ' ' ~ ' � '~ Mobile#
Will Choate
Nome of Individual to Contact(if Registered Agent is a company)

(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.
PAuL. MOUSr0 Wit-As PTRZctof-
Type or print name Title or Authority
e.,,,
oq/„ /202,
Signature Date
I, 5 j d,n%c. CM51- , a Notary Public of the County of_ O ciceab
Gtovg'1 a
State of NeFt44-Caraliaa, hereby certify that Qom\ V\okASkaukws 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 2 2- day of Seiefc"`^ , 20_7.-3
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