NCC241371_FRO Submitted_20240515

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 NCGO1 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 Depot Park Shelby
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Cleveland City or Township Shelby
Graham Street 35.289081° -81.541959°
Highway/Street Latitude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 8/1/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreational
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.7 ac
6. Amount of fee enclosed: $500.00 . 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).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑✓ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rick Howell E-mail Address rick'[e-mail]
Phone: Office# [phone] Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Shelby [phone]
Name Phone: Office# Mobile#
PO Box 300 S Washington St
Current Mailing Address Current Street Address
Shelby, NC 28150 Shelby, NC 28150
City State Zip City State Zip
10. Deed Book No. 1804 Page No. 1432 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).
City of Shelby [e-mail]
Company Name E-mail Address
PO Box 300 S Washington St
Current Mailing Address Current Street Address
Shelby, NC 28150 Shelby, NC 28151
City State Zip City State Zip
Phone: Office# [phone] 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 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)

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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 by any change in the information provided herein.
] 1CK- "1-l0 1 �a►�a�-
Type or p i ame Title or u ho ity
7 ./Ri.e_ 3
Signatu Date
I, 13r•ian4- 1'J cd'^2 , a Notary Public of the County of C(ev4 (AAcl
State of North Carolina, hereby certify that /2x'Ic Lc <( appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this y day of /Vlwrc L , 20 2'•(
� ........ Notary
• Seal • '•
W'' TARY ;�
NO My commission expires 1 t I3' 20 2
PUBt '-
1 l•
'••4AND CU