NCC220625_FRO Submitted_20220215

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. Hidden Valle Water System Improvements Project
1. Project Name y yem p
2.
3
4
Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street W Sugar Creek Rd Latitude 35.286122 - Longitude-80.794250
Approximate date land -disturbing activity will commence. 10/4/2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.64
6. Amount of fee enclosed: $ 455 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 Amy Vershel E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached
Name
Telephone Fax Number
Current Street Address
Current Mailing Address
Zip City State Zip
City State
10. Deed Book No.
Page 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
5100 Brookshire Blvd
5100 Brookshire Blvd
Current Mailing Address
Current Street Address
Charlotte, NC 28216
Charlotte, NC 28216
City State
Zip City State Zip
704-336-7600
Telephone
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address
N/A
City
Telephone N/A
Current Street Address
N/A
State Zip City State Zip
Fax Number N/A
(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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City
Telephone N/A
OLAI
E-mail Address
N/A
Current Street Address
N/A
State Zip City State Zip
Fax Number N/A
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.
►lose h C. Wilson
Ty r pri t name
Sig ure
Charlotte Water Chief Engineer
Title or Authority
i9e5l":;111421
Date
I, Notary Public of the Co` unty of
- - b4�
State of North Carolina, hereby certify that 1 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,
►t►usifoil/
p+ S I MP`'•�,,.
�eal
����►F100 fill NB U RGO,�+�`
this Ui' day of 20
VNqAA
Nat
My commission expires ` ].