NCC221999_FRO Submitted_20220527

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. North End Around Taxiway Package 1
1 . Project Name
2
3
4
Location of land -disturbing activity: County Mecklenburg city or Township Charlotte
Highway/Street Airport Overlook Dr. Latitude 35.230669 - Longitude 80.956833
Approximate date land -disturbing activity will commence: May 12, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.) Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 233
6. Amount of fee enclosed. S 15,145.00 — 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 No Enclosed X
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity�
Nam, Eric Rysdon E-mail Address [e-mail]
Telephone [phone] Cell # 704-808-371 Fax #
E0
Landowner(s) of Record (attach accompanied page to list additional owners)�
City of Charlotte
Name Telephone Fax Number
600 E. 4th Street 5501 Josh Birmingham PKWY
Current Mailing Address
Charlotte, NC 28202
City
10. Deed Book No.03089
State
Current Street Address
Charlotte, NC 28202
Zip City State
A r, r,
Z-1p
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 - Charlotte Douglas International Airport Jeffrey. [e-mail]
Name E-mail Address
P.O. Box 19066 5601 Wilkinson Blvd
Current Mailing Address
Charlotte NC 28208
City State Zip
Telephone [phone]
Current Street Address
Charlotte NC 28208
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
Current Mailing Address
E-mail 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:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
C ity
Fax Number
State Zip
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.
_je'-w
Type or pri t name Title or A6thority
S'�Rfa to Date
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04
a Notary Public of the County of
I
State of North Carolina, hereby certify that C1641 appeared
personally before me this day and being dul� i4orn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,
owl I Ii"i"
G.
NOTARY
PUBLIC
0
Ili URG
//110 I it 10"
this day of 20
Notary
My commission expires ZL- �, --,,?- ed,; 3 —