NCC221032_FRO Submitted_20220316

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 NIA in the blank.)
Part A. PROJECT CARDINAL
1. Project Name
2. Location of land -disturbing activity: CountyCABARRUS City or Township CONCORD
Highway/Street 1420 CONCORD PKWY SOUTH Latitude 35.392689 Longitude-80.630764
3. Approximate date land -disturbing activity will commence: MARCH, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): MANUFACTURING
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 66.45
6. Amount of fee enclosed: $ 6,700 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 AL MILLER E-mail Address [e-mail]
Telephone Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BOOTSMEAD LAND LLC
Name Telephone Fax Number
1717 S. BOULDER AVE STE 400 1717 S. BOULDER AVE STE 400
Current Mailing Address Current Street Address
TULSA OK 74119 TULSA OK 74119
City State Zip City State Zip
10. Deed Book No. 10921 Page No. 0060 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.
Gilbane Building Co. [e-mail]
Name
620 S. Tryon Street Suite 350
Current Mailing Address
Charlotte North Carolina 28202
City
State Zip
E-mail Address
620 S. Tryon Street Suite 350
Current Street Address
Charlotte North Carolina 28202
City
State
Zip
Telephone. Fax Number
[phone] [phone]
____ �_

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
Current Mailing Address
City
Telephone
E-mail Address
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 E-mail Address
Current Mailing 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.
Al Miller
Type or print name
Signature
Anita Taylor
Vice President
Title or Authority
January 20, 2022
Date
a Notary Public of the County of
State of North Carolina, hereby certify that Al Miller 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 20th day of January
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