NCC216079_FRO Submitted_20211201

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. TATTERSALL SDIP
1. Project Name
2. Location of land -disturbing activity: County MECKLENBURG City or Township CHARLOTTE
Highway/Street HOPECREST DR Latitude 350 7'30.50"N Longitude 80051'33.26"W
3. Approximate date land -disturbing activity will commence: 07/01 /2019
4. Purpose of development (residential, commercial, industrial, institutional, etc.): MUNICIPLE STORMWATER
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.5
6. Amount of fee enclosed: $ 260.00 . 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 TYLER HOWELL E-mail Address Tyler. [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SEE ATTACHED LIST
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. SEE ATTACHED LISTPage No. 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.
CITY OF CHARLOTTE [e-mail]
Name E-mail Address
600 E 4th St 600 E 4th St
Current Mailing Address Current Street Address
CHARLOTTE NC 28202 CHARLOTTE NC 28202
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:
Name
Current Mailing Address
City
Telephone,
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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 be any change in the information provided herein.
TYLER HOWELL PROJECT MANAGER
Type or print name
i ature
Title or Authority
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Date
I, I1' . a Notary Public of the County of ;
State of North Carolina, hereby certify that c'4` appeared
personally before me this day and being dufiy sworn acknowledged that the above form was
executed by him.
Witness my hand and no flr1�l seal, this
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