NCC223537_FRO Submitted_20221013

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 NIA in the blank.)
Part A. Bradfield Farms - Silverton Water Interconnect
1. Project Name
2. Location of land -disturbing activity: County Cabarrus City or Township
Highway/Street Tearoyal Ct Latitude 36.258818 Longitude-80.644740
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Infrastructure
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.00 AC
6. Amount of fee enclosed: $ 130.00 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:
Name Travis Dupree E-mail Address [e-mail]
Telephone [phone] Cell # 864-395-3571 Fax # NIA
9, Landowner(s) of Record (attach accompanied page to list additional owners):
Carolina Water Service Inc of NC 864-203-0233 NIA
Name Telephone Fax Number
4944 Parkway Plaza Blvd, Suite 375 130 South Main Street, Suite 800
Current Mailing Address Current Street Address
Charlotte NC 28217 Greenville SC 29601
City State Zip City State Zip
10. Deed Book No. 12197 Page No. 213 Provide a copy of the most current deed.
Part B. 13669 151
1. Company(les) 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 companyorfrrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Carolina Water Service Inc of NC [e-mail]
Name E-mail Address
4944 Parkway Plaza Blvd, Suite 375 130 South Main Street, Suite 800
Current Mailing Address Current Street Address
Charlotte NC 28217 Greenville Sc 29601
City State
Telephone [phone]
Zip City
Fax Number NIA
State
Zip

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
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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
E-mail Address
Current Street Address
City State Zip City
Telephone 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.
Travis Dupree Vice President
Type or print name Title or Authority
10/21/2021
Signature Date
I, Kotary Public of the County of i' L �i 1
State of fi Carolina, hereby certify that �uv �U �'�� appeared
personal l before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of 120
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