NCC222577_FRO Submitted_20220725

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
07.06 EROSION CONTROL FORMS AND CHECKLISTS
07.06.01 EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
No person may initiate any land -disturbing activity as defined in Chapter 158 of the Monroe City Code prior to
completion of this form, and an applicable and acceptable erosion and sedimentation control plan has been approved by
the City of Monroe Engineering Department. (Please type or print)
Part I
1. Name of Project NC BioGas
2. Address where land disturbing activity will take place 325 Acme Drive
Monroe, North Carolina 28112
3. Approximate date disturbing activity will commence 7 / 6 / 2022
4. Purpose of development (residential, commercial, industrial, etc.) Industrial
5. Total acreage of land to be disturbed or uncovered 6.62
6. Amount of fee enclosed (fee will be the amount of current policies per acre multiplied by the total number
of acres or any part of an acre from number 5. i.e. 7.28 acres equals 8 acres.) $ 2 0 0
7. Agent to contact should sediment control issues arise during land disturbing activity
NC BioGas, Anwar Shareef 919-882-3901
Name Stimmel Associates, Kelway Howard Phone [phone]
8. Landowner(s) of Record (use blank page to list additional owners)
Name NC BioGas, LLC Name
Mailing Address 8601 Six Forks Rd Mailing Address
Raleigh, NC 27615
Street Address 8 601 Six Forks Rd Street Address
Raleigh, NC 27615
Phone
9. Indicate Book and Page where deed of the property where land disturbing activity will take place is recorded
(use blank page to list additional owners)
Book 8110 Book 12 8
Page Page
10. Tax Map Parcel Number where land disturbing activity will take place 0 9 __ 12 2 -- 0 01A
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
Person(s) or firm(s) who are financially responsible for this land disturbing activity (use blank page to list
additional owners)
Name NC BioGas, LLC Name
Mailing Address 8 601 Six Forks Rd Mailing Address
Raleigh, NC 27615
Street Address 8601 Six Forks Rd Street Address
Raleigh, NC 27615
Phone [phone] Phone
Fax Fax
2. A) If the Financially Responsible Party is not a resident of North Carolina, give name and address of a North
Carolina Agent
Name of Registered Agent
Mailing Address
Street address City State Zip
Phone Email Fax
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 the name and street address of the Registered Agent:
Name of Registered Agent
Mailing Address �.
Street address City State Zip
Phone Email Fax
3. The above information.is true and correct to the best of my knowledge and belief and was provided by me
under oath. i agree to provide corrected information should there be any change in the information provided
herein. (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 authority to execute instruments
for the financially responsible person)
Type or Print Nam Title
Signatur Date C419' •z7
L fir.., % Ka c-htoAc- CC_K_, a Notary Public of the County of ti)Ciki_..._._...._._._..__ State of North Carolina,
hereby certify that __Sj_e-d Anwc..r ShClX ft:L appeared personally before me this day and being drly sworn acknowledged
that the above form was executed by him.
�� '.IhWi#@ tk{.and notarial seal, this �._ day of rl� _ a0 a ------------
=REAL
( tart' )
�y 052 ���V �� My commission expires -�_ A a
PU � 07-19 Pen -nits, Checklists, and Forms
°� ,,,,,,.. o Division 07