NCC220684_FRO Submitted_20220209

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name Concord Substation - Ruben Linker
2. Location of land -disturbing activity: County Cabarrus City or Township_ Concord
Highway/Street Ruben Linker Road — Latitude_ 35022'50.90"N _ Longitude_ 80042'02.70"W
3. Approximate date land -disturbing activity will commence:_ February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_ Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 2.52 ac
6. Amount of fee enclosed: $_ 195.00 . The application fee of $65.0D 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_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott Chunn E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Concord
Name Telephone Fax Number
P.O. Box 308 635 Alfred Brown Jr. Court SW
Current Mailing Address Current Street Address
Concord NC 28026 Concord NC 28025
City State Zip City State Zip
10. Deed Book No. 14710 Page No. 0048 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 Concord [e-mail]
Name E-mail Address
P.O. Box 308 635 Alfred Brown Jr. Court SW
Current Mailing Address Current Street Address
Concord NC 28026 Concord NC 28025
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
Telephone
State Zip City
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
E-mail 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.
SG oT�` 114%17 D L-Pv-rS/ o/fZ i� oG ;1 GTf1iG S�'s JCS
Type or print name Title or Authority
Signature Date
VOLftQ_gL , a Notary Public of the County of c--"-A ghPULA5
State of North Carolina, hereby certify that _N��a►-� 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 D(CEM, , 20
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