NCC221756_FRO Submitted_20220509

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 Environment and Natural Resources. (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.
1. Project Name
f•
3
4
Greenbrier Office Park Expansion
Location of land -disturbing activity County Mecklenburg City or Township Charlotte
Taggart Creek Rd
Highway/Street Latitude 35.2270 Longitude -80.9210
Approximate date land -disturbing activity will commence. 6/1/22
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 1.1
6. Amount of fee enclosed: $ 130 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No . Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name BERNIE FUNCK E-mail Address [e-mail]
Telephone [phone] Cell # 704-400-6055 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BISHOP DRIVE ASSOCIATES LLC 704-519-0775
4240 Morris Field Dr
Current Mailing Address
rharinttem NC 2R20R
State
10. Deed Book No. 35679
Telephone
Fax Number
4240 Moriri--, lFic-ld Or
Current Street Address
Charlotte NC 28208
Zip City State Zip
Page No. 219 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
RANGER CONSTRUCTION COMPANY INC e+nrn
Name
4240 Morris Field Dr
Current Mailing Address
Charlotte NC
awi
E-mail Address
4240 Morris Field Dr
Current Street Address
28208 Charlotte NC 28208
State Zip City
State

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:
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State 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.
ELIZABETH FUNCK AGENT
Type or print name
Signature
Title or Authority
Date
I, M h . DVeVNVNW , a Notary Public of the County of M_Ift�1eV1b1�1/q
State of North Carolina, hereby certify that E I I N k-t-k EwndL 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 _3 of 1r�G1� 20 22
LMEGAN A. DRENNANpNOTARY PUBLICrMecklenburg County
North Carolinamission Expires Ap, 1:, 2027

Notary
Seal ' L
My commission expires