NCC221680_FRO Submitted_20220504

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Rocky River Regional WWTP Expansion DB Phase 3
1. Project Name
2. Location of land -disturbing activity: County CabarrUS City or TownshipConcord
HighwayiStrest 6400 Breezy Lane Latitude 35.327717 Longitude-80.540516
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas ):15.88 ac
6. Amount of fee enclosed: $ 3,600 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
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 Thomas Hahn, PE E-mail Address t•[e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WSACC
[phone]
Name
Telephone Fax Number
232 Davidson Hwy
232 Davidson Hwy
Current Mailing Address
Current Street Address
Concord NC
28027 Concord NC 28027
City State
Zip City State Zip
10. Deed Book No.1351
Page No. 213 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.
WSACC
[e-mail]
Name
E-mail Address
232 Davidson Hwy
232 Davidson Hwy
Current Mailing Address
Current Street Address
Concord NC
28027 Concord NC 28027
City State
Zip City State Zip
Telephone [phone]
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:
NIA
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Chad VonCannon [e-mail]
Name of Registered Agent E-mail Address
232 Davidson Hwy 232 Davidson Hwy
Current Mailing Address Current Street Address
Concord NC 28027 Concord NC 28027
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Brown and Caldwell [e-mail]
Engineering Firm or other consultant E-mail Address
Kim Devendorf 315-401-3634
Individual contact person (type or print) 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 attomey-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.
Chad VonCannon Engineering Director
Type�rint name Title or A7c�
rity
�!
ignature Date
I, �Cl.K VoQ 1 1 IQCI` mw r (Vdy' % ,``a Notary Public of the County of Caloar
State of North Carolina, hereby certify that CAN(A nncayy\f> \ 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 day of r�.l�' kk&r�, 20 �
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y•'� My commission expires