NCC240519_FRO Submitted_20240223

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity on one or more acres as covered by Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the City of Charlotte.The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion and Sedimentation
Ordinance.If the financially responsible party is out of State, a North Carolina agent must be assigned. All relevant
items on this form must be filled out accurately and completely
Please Type or Print
PART A
1. Project name: Farmington Retail Outparcel F
2. Address of land—disturbing activity: Not assigned yet
3. Approximate date land-disturbing activity will commence: July 1 2023
on
4. Purpose of Development(Residential,Commercial,Industrial, etc.): Commercial Year
5. Total acreage of land to be disturbed or uncovered: 2 '2
6. List total site acreage: 2 .0 5
7. Landowners of Record(attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s) financially responsible as listed in Part B, item 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Rocky River Road Associates, LLC
Name:
Address: 2400 South Blvd Ste 300
Charlotte, NC 28203
7Telephone: 0 4 .5 l 7 . l 610 Fax:
(Area Code)
Email Address: [e-mail] (Area Code)
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
8. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or
instruments) Book 2 4 7 g 2 Page 354 Book Page
Book Page _ Book Page
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s)or firm(s)financially responsible for this land-disturbing activity(Note:If the financially responsible
person(s)orfirm(s)has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: Rocky River Road Associates, LLC
Address: 2400 South Blvd Ste 300
Charlotte, NC 28203
Telephone: 7 0 4 .517 . 1610 Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. If the Financially Responsible Party is not a resident of North Carolina,give name and street address of the
designated North Carolina agent:
Person or Firm:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the fmancially responsible person if an individual or by an
officer, director,partner, attorney-in-fact, or other person with authority to execute instruments for the
fmancially responsible company or entity,if not an individual.)
George Macon Owner
Printed N:I,e Title
i/ 5 . 16.23
Signature Date
I~ steuoterttJ1. AU..0-$1 , a Notary Public of the County
of A,IerACA.aava c , State of Aloairs, C aaeu,uw , hereby
certify that Ceb17.6C /NAeg,4,4% personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this 14, 'i " day of /W AY , 20 Z3
Notary Signature'"----: /ll
My Commission expires: el Zo ������ T t ��/r
• � � .
(CO)
NOTq�r ��
pUeLlc '
, .%s. 'i,,� RG Cb '"
: i i l k"charlottenc.gov //
Storm Water Services—Land Development
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone:[phone]
http://charlottenc.gov/developmentcenter
Rev.09/2021 Page 2