NCC240180_FRO Submitted_20240123

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
S PE
3
No person may initiate any land-disturbing a t ity o one or ore acr dq - es acovered 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Union County Shrine Club { {,
Q `g.z
2. Location of land-disturbing activity: County Union City or Township 4100`�Sa "abtf <R
egion�',(,00
Highway/Street US 601 Latitude(decimal degrees) 34.8258 Longitude(decimai degrees) 80,4227 � Q`
3. Approximate date land-disturbing activity will commence: October 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.16 ac
6. Amount of fee enclosed $200 . The Express Permitting application fee is a dual charge. The normal
fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition,
the Express Permitting supplement is$250 per acre up to eight acres,after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks should
be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name William Cox E-mail Address chickeis10(c�fronter.com
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Union Shrine Properties INC 704-506-0626
Name Phone: Office# Mobile#
124 Brightland Run 124 Brightland Run
Current Mailing Address Current Street Address
Monroe NC 28112 Monroe NC 28112
City State Zip City State Zip
10. Deed Book No. 08739 Page No. 0014 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Union Shrine Properties INC 704-506-0626
Name Phone: Office# Mobile#
124 Brightland Run 124 Brightland Run
Current Mailing Address Current Street Address
Monroe NC 28112 Monroe NC 28112
City State Zip City State Zip
Phone: Office# Mobile# [phone]
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 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: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(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 of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name 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
(d) If 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:
Wolf Trail Engineering, PLLC Doug( WolfTrailEngineerinq.com
Engineering firm or other consultant E-mail Address
Doug Buchanan, PE 704-533-2327
Individual contact person (type or print) Phone: Office# Mobile#
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.
William Cox President
Type or print name Title or Authority
Date
Signature ?/-"-- (77:v
g
I,{a. 4 e,e, £ )reeX) , a Notary Public of the County of 4ee Reel
State of North Carolina, hereby certify that 11`10 ea X 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 gi day of 0
L -dr
s�
ota17
-"
i
Seal My commission expires U3/04 d2r
B.JALEEL GREEN
NOTARY PUBLIC
Mecklenburg County
North Carolina
My Commission Expires Mar.3,2025

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.