NCC222670_FRO Submitted_20220725

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. Kannapolis Crossing Clearing
1. Project Name
2. Location of land -disturbing activity: CountyROWan County City or Township Kannapolis
Highway/Street Old Beatty Ford Rd. Latitude 35.9209 Longitude 80.3414
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 28.1
6. Amount of fee enclosed: $ $1885 . 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:
Name Carolyn Martin E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kannapolis Crossing, LP 225 924 7206
Name Telephone Fax Number
450 Main Street
Current Mailing Address Current Street Address
Baton Rouge LA 70801
City State Zip City State Zip
10. Deed Book No. 1339 Page No. 861 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.
Kannapolis Crossing, LP [e-mail]
Name E-mail Address
450 Main Street 450 Main Street
Current Mailing Address Current Street Address
Baton Rouqe, LA 70801 Baton Rouge, LA 70801
City State
Telephone [phone]
Zip City
Fax Number
State
W.

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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 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.
Carolyn E. Martin
Type print name
Signature
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Manager
Title or Authority
T. 7. 2-,o2-i
Date
R. l
'L 0411, Yw.-44 • a Notary Public of the Garin of
State of Ne4h-Gaf-Gl+na, hereby certify that appeared
personally before me this day and being duly s orn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
Andrew T. M=ins
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