NCC216836_FRO Submitted_20211210

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. Industrial Center Circle NW
1. Project Name
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street 1700 Industrial Center Circle Latitude350 15' 33.336" N Longitude800 45' 41.004" W
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.) -Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.62
6. Amount of fee enclosed: $130 (2X65) . 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 Frank Shepherdson E-mail Address [e-mail]
Telephone[phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Washburn 3100 704-200-9208
Name Telephone Fax Number
230 Wonderwood Dr 230 Wonderwood Dr
Current Mailing Address
Charlotte NC
City State
10. Deed Book No.35944
Current Street Address
28211 Charlotte NC 28211
Zip City State Zip
Page No.554-558 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.
Washburn 3100 [e-mail]
Name E-mail Address
230 Wonderwood Dr
Current Mailing Address
Charlotte NC 28211
city
State Zip
Telephone 1411 ' 1:
230 Wonderwood Dr
Current Street Address
Charlotte NC 28211
City State Zip
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:
Current Mailing Address
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
8d If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed namo, attach a copy of the Certificate of Assumed Nomnm' If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
The above information katrue and correct tnthe best Ofmyknowledge and belief and was provided
bvmneunder oath (This form must besigned h«the Financially Responsible Person ifanindividual
or his etborney-in-fooL, or if not an individual, by an Vfficer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information should there be any change in the information provided herein,
Frank Shepherdson Owner
Type or printn8mKe Title or Authority
Frank SheDhendrnn 7Y13/2021
Signature Date
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[ a Notary Public mfthe County of
State of North Carolina, hereby certify appeared
pmnG0O@||y before 0e this day and being duly Sw0nl 8chDVm/8dged that the above form was
executed bVhim.
Witness mnyhand and 8yDf .2
6.
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Seal
My C0Dln0iSsiOD expires