NCC220801_FRO Submitted_20220218

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.
Project Name FC11 Project Independence
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street NC-49 Latitude 35°22'10.6"N Longitude 80°33'41.0"W
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 27 AC
6. Amount of fee enclosed: $ 2,700 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
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 Ryan Price E-mail Address Ryan.Pricea-whiting-turner.com
Telephone [phone] Cell # 410-977-1178 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kroger Fullfillment Network LLC 502-500-0117
Name Telephone
1014 Vine Street
Current Mailing Address
Cincinnati OH 45202
City State Zip
Current Street Address
City
State
Fax Number
Zip
10. Deed Book No. 7705 Page No. 298 Provide a copy of the most current deed.
Part B.
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.
Kroger Fullfillment Network LLC
Name
1014 Vine Street _
Current Mailing Address
Cincinnati OH 45202
City State Zip
erin.birch(a-)kroger.com
E-mail Address
1600 Ormsby Station Court
Current Street Address
Louisville KY 40223
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:
Matt Edwards matt. edwardsAkimIey-hom.com
Name E-mail Address
200 South Tr on St Suite 200
Current Mailing Address
Charlotte
City
Telephone [phone]
NC 28202
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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). l agree to provide
corrected information should there be any change in the information provided herein.
Type or print name Title or Authority
t Alx 1 .A `' VZJ i f I Z02 L
Signature Date
a Notary Public of the County of Se
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State of Ale4.1h C-2-Areliga, hereby certify that t°' appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witnes,4`I` braWb' �tarial seal, this q day of `Oecp w\,�be ` , 20Ilk
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COMMISSION U .•`
EXPIRES •, S Notary
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