NCC223590_FRO Submitted_20221101

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 and Grubbing
1. Project Name
2. Location of land -disturbing activity: County Rowan City or Township Kannapolis
Highway/Street SR 1221 Latitude35.534 Longitude-80.565
3. Approximate date land -disturbing activity will commence: April 1 st, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 99.6 acres
6. Amount of fee enclosed: $ 10,000 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matthew Graham E-mail Address [e-mail]
Telephone [phone]
Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HCP Kannapolis Crossing Land Ventures, LLC 919-838-7205
Name Telephone Fax Number
400 Frank W Burr Blvd, Suite 8
Current Mailing Address Current Street Address LL
Teaneck, NJ 07666
City State Zip City State Zip
10. Deed Book No. 1382 Page No. 416 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.
HCP Kannapolis Crossing Land Ventures, LLC [e-mail]
Name E-mail Address
400 Frank W Burr Blvd, Suite 8
Current Mailing Address Current Street Address
Teaneck, NJ 07666
City State Zip City
Telephone[phone] Fax Number
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.,
CT Corporation System
Name
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh, NC 27615
City
State Zip
E-mail Address
Current Street Address
City
Telephone[phone] 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
City
E-mail Address
Current Street Address
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.
Mathias G. Linden
Type or print name
Sig ature
Jesse T. Buchanan
Managing Director
Title or Authority
2/15/2022
Date
, a Notary Public of the County of
Wake
State of North Carolina, hereby certify that Mathias G. Linden appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 15th
Seal
JESSE T. BUCHANAN
NOTARY PUBLIC
WAKE COUNTY, N.C.
_day of February 2022
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My commission expires a '�