HomeMy WebLinkAboutNCC221083_FRO Submitted_20220331FINANCIAL 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. Tractor Supply Company - Shelby
1. Project Name
6
3
4
Location of land -disturbing activity: County Cleveland City or Township Shelby
Highway/Street_'80 Earl Road Latitude 35.273639 _ Longitude-81.531940
Approximate date land -disturbing activity will commence: 2/15/2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7'76 (adding 2.28)
6. Amount of fee enclosed. $ 300 (for add. disturbed) 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 X --No-- Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Wendy Fulton E-mail Address wfulton@thekeithcorp.com
Telephone 704-365-6000
Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Partnership Alliance Company, LLC
Name Telephone Fax Number
152 Farmington Road
Current Mailing Address
Shelby, NC 28150
City State
10. Deed Book No. 1722
Current Street Address
Zip City
Page No. 377
State
Zip
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.
TKC CCCII, LLC wfulton@thekeithcorp.com
Name E-mail Address
4500 Cameron Valley Pkwy #400
Current Mailing Address
Charlotte, NC 28211
City State
Telephone 704-365-6000
Current Street Address
Zip City State Zip
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Te#ephone 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.
Wt I&,t v\
Type a
e Title o Authority
7OI�I�I
Signature U Date
I, ill V IL-) DQ#-V\t , a Notary Public of the County of _+ [ ; CteYA�Ik^
State of North Carolina, hereby certify that VV t*\DW 9A kIk SV%- appeared
personally before me this day and being duly sworn 9&nowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of ��i'� IlJ` V , 20 c11
RI I+Cr�f'*
Seal ' �� tJatary Public
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- County -
My Comm. Exp.
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