NCC217137_FRO Submitted_20220111

FINANCIAL RESPONSiBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. MHS Charter Hangar
1. Project Name 9
2. Location of land -disturbing activity: County CabarrUS City or Township Concord
Highway/Street Aviation Blvd Latitude 35.392110 Longitude-80.710387
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Airport Hangar
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10
6. Amount of fee enclosed: $ 2,130 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a Gelling amount In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDEN R.
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 Shannen Thompson E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Concord 704-920-5555
Name Telephone Fax Number
35 W Cabarrus Ave 35 W Cabarrus Ave
Current Mailing Address Current Street Address
Concord NC 28025 Concord NC 28025
City State Zip City State Zip
10. Deed Book No. 773 Page No. 342 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 companyorrum is a sole proprietorship,
the name of the owner or manacer may be iisted as the financially responsible party.
MHS Travel & Charter, Inc. [e-mail]
Name E-mail Address
7700 Forsyth Blvd 7700 Forsyth Blvd
Current Mailing Address Current Street Address
Saint Louis MO 63105 Saint Louis MO 63105
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:
CT Corporation System
Name
160 Mine Lake Ct., Suite 200
Current Mailing Address
Raleigh NC 27615-6417
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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 Zip
E-mail Address
Current Street Address
City
Telephone Fax Number
State Zip
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
LandDesign, Inc.
Engineering Firm or other consultant
Shannen Scott Thompson
Individual contact person (type or print)
[e-mail]
E-mail Address
704-333-0325
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 be
any change in the information provided herein.
a
Type or ame Title or Authority
It
Signature Date
I, 4a-Hyr W(n Rt7u i i) , a Notary Public of the County of �< s LUl,1l s
State of Pd 4xenalir-ra, hereby certify that �u 1�a-�4-fr1Q,W S appeared personally
before me this day and being duly sworn acknowledgeh that the above form was executed by him.
Witness my hand and notarial seat, this day of k� G P_MbZr , 20,,-),t _
,�e64� dUW1A_ Z7e�&
Notary
Seal
HEATHER LYNN RIZZELLO My commission expires
NOTARY PUBLIC TARY SEAL
STATE OF MISSOURI
COMMISSIONED FOR ST. LOUIS COUNTY
W COMMIS ID N E89 ES MAR. 25, 2022