NCC221124_FRO Submitted_20220418

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. Cutchin Drive Storm Drainage Improvement Project
1. Project Name
2. Location of land -disturbing activity: County Mecklenburg City or Township charlotte
Highway/Street multiple Latitude35.139665 Longitude-80.8208734
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Storm Drain Improvement
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.6
6. Amount of fee enclosed: $ 600 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Shawn C McDonald, PE, CPESC E-mail Address Shawn. [e-mail]
Telephone [phone] cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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.
City of Charlotte Shawn. [e-mail]
Name
i�u_trrr
600 East 4th Street - 12th Floor 600 East 4th Street - 12th Floor
Current Mailing Address
Charlotte NC
City
State
Telephone [phone]
Current Street Address
28202 Charlotte NC
Zip City State
Fax Number704-336-0473
28202
M

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 State
Telepho
E-mail Address
Current Street Address
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
State
E-mail Address
Current Street Address
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). I agree to provide
corrected information should there be any change in the information provided herein.
Shawn C McDonald, PE, CPESC Project Manager - Charlotte/Mecklenburg Storm Water Services
Type or print
Signature
Title or Authority
3/i,�,p /2o zz
Date
1,af 1' � a Notary Public of the County of H��' �&)� ''7A'�
State of North Carolina, hereby certify that _ (_ •�� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 11
Witness my hand and notarial seal, this 1t day of t r '`' ` 20
cpTAly�„ Z i_ Notary
Pr
, 2 My commission expires 1
-n,� �/N4,