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HomeMy WebLinkAboutNCC220801_FRO Submitted_20220218FINANCIAL 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 410-977-1178 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 502-500-0117 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 704-954-7493 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 l�E�vTvcx.� 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 1s p COMMISSION U .•` EXPIRES •, S Notary 001 ,�''� �q+RGE.' ���• My commission expires