NCC220893_FRO Submitted_20220225

NaUR° °
Mecklenburg County Soil Erosion and
�y' Q Sedimentation Control Ordinance
GpFinancial Responsibility/Ownership Form
M R
No person shall initiate any land -disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. If the
financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken: Subaru of South Charlotte
2. Address of land -disturbing activity:
10410 Cadillac St, Pineville 28134
3. Approximate date land -disturbing activity will commence: January 1 2022
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): commercial
5. Approximate acreage of land to be disturbed or uncovered: 9.33
6. Total site acreage: 10.80 ac
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: WOM PREP, LLC
Address: 9201 South Blvd
Charlotte, NC 28273
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 35947 page 670 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: WOM PREP, LLC
Address: 9201 South Blvd
Charlotte NC 28273
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: N/A
Address:
Telephone: Fax:
Email Address:
3. The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath. ("Phis form must be signed by the financially responsible
person if an individual or by an officer, director, partner, attorney -in -fact, or other person
with authority to execute instruments for the financially responsible company or entity, if not
an individual.)
Print Title
11.3.A!
Signature Date
I Paul D McNaught , a Notary Public of the
Countyof State of , hereby
certify that S�'ey C' fP"4 e "— personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal(this s . ck day of fil—
Notary Signature: _
My Commission ex Tres:
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave. r*
Charlotte, NC 28208-5237 �f'ek
Phone [phone]f1tltr���