NCC215459_FRO Submitted_20211001

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. Cabarrus Count EMS Headquarters
1. Project Name y
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street Cabarrus Ave, W Latitude N 35.395 Longitude W 80.609
3. Approximate date land -disturbing activity will commence: 7.15.2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.48
6. Amount of fee enclosed: $ 520.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Rob Cook E-mail Address [e-mail]
Telephone [phone]
Cell #
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cabarrus County
704-920-3201 704-920-3203
Name
Telephone Fax Number
65 Church St S.
(same)
Current Mailing Address
Current Street Address
Concord NC
28025
City State
Zip City State Zip
10. Deed Book No. 3047
Page No. 221 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.
Vannoy Construction
[e-mail]
Name
E-mail Address
1608 US Hwy 221, North
same
Current Mailing Address
Current Street Address
Jefferson NC
28640
City State
Zip City State Zip
Telephone [phone] Fax Number

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:
(N/A)
Name
Current Mailing Address
E-mail 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:
(N/A)
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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.
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Type or print name
1_V_A
Title or Authority
S/14/Z
Signature Date
I, a Notary Public of the County of
State of North Carolina, hereby certify that V80 Cc'�b 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 -'_day of
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My commission expires
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