NCC220628_FRO Submitted_20220204

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 Environment and Natural Resources. (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.
1. Project Name Carolina Pets Animal Hospital
2. Location of land -disturbing activity: County Union City or Township_ Wesley Chapel
Highway/StreetWaxhaw-Indian Trail Rd Latitude 3500'17" Longitude-80040'56"
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.58
6. Amount of fee enclosed: $ 195 . 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 x No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Heather Meyers E-mail Address [e-mail]
Telephone--[phone] T Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NGM Real Estate, LLC [phone]
Name Telephone Fax Number
6505 Carriage Lane 6505 Carriage Lane
Current Mailing Address Current Street Address
Waxhaw NC 28173 Waxhaw NC 28173
City State Zip City State Zip
10. Deed Book No. 7691 Page No. 0708 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
NGM Real Estate, LLC [e-mail]
Name E-mail Address
6505 Carria a Lane 6505 Carriage Lane
Current Mailing Address Current Street Address
Waxhaw NC 28173 Waxhaw NC 28173
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
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 be any change in the information provided herein.
Heather Meyers
Type or print name
Signature
President
Title or Authority
69 101 2-
Date
a Notary Public of the County of V n l 6A
State of North Carolina, hereby certify that L' 4�,,r f6ee r 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 seal, this day of . fU ILA _ 2p l
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