NCC222686_FRO Submitted_20220726

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Lincoln Commerce Center West
2. Location of land -disturbing activity: County LI ncoI n City or Township Denver, NC
Private Access Drive served 35.461119-81.012028
Highway/Street[
ighway/Street fromNwintersedonofNCHwy Latitude(decimaldegrees) Long itude(decimaldegrees)
73 and NC Hwy 16 6/ 15/2022
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):88 Acres
6. Amount of fee enclosed: $$87800.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name -Chris Urquhart
Phone: Office # 704-236-2440
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CHIPT Charlotte Lincoln West, LLC 704-236-2440
Name
4064 Colony Road, Suite 405
Current Mailing Address
Charlotte, NC 28211
City r�State
10. Deed Book No.31 1 3
Phone: Office #
704-236-2440
Mobile #
4064 Colony Road, Suite 405
Current Street Address
Charlotte, NC 28211
Zip City
Page No.90-96
State
0
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
CHIPT Charlotte Lincoln West, LLC
Company Name
3889 Maple Ave, Suite 200
Current Mailing Address
Dallas, TX 75206
City State Zip
Phone: Office # 704-236-2440
[e-mail]
E-mail Address
3889 Maple Ave, Suite 200
Current Street Address
Dallas, TX 75206
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
CT Corporation System
Name of Registered Agent
160 Mine Lake Ct, Suite 200
[e-mail]
E-mail Address
160 Mine Lake Ct, Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office # 704-25au-9147 Mobile # [phone]
Matt Cochrane
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the rtificate of Assumed Name.
Cq
I P T C & 4� Gf�6011, s Lac
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Title or Authority
6/
Date
I, `�"-41d(o,,, S4C-VG%s , a Notary Public of the County of H ecQ-1c., 5, ,g
State of North Carolina, hereby certify that I'Aa�y appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of 3"vi , 20 2 Z
Seal
BRANDON STEVENS
NOTARY PUBLIC
Mecidenburg County
North Carolina
Commission Evires Sept. 29, 2M
Notary
My commission expires S e w 'l . 2 4. 2 a Z