NCC230157_FRO Submitted_20230127

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 NIA in the blank.)
Part A.
2
3.
Project Name: USDA Sewer Improvements
Location of land -disturbing activity: County: Cabarrus City or Township: Town of Mount Pleasant
Highway/Street: Various — See Plans Latitude: 35.398969 Longitude:-80.435628
Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.) Utility Construction
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.65 acres
6. Amount of fee enclosed: L700. 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 0 Enclosed ® No O
1.1
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Randy Holloway, Town Manager E-mail Address: HOIIowayR(cDrntpleasantnc-us
Phone: Office # (7041436-9803 Mobile #
Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Mount Pleasant
Name
Phone: Office #
Mobile #
8590 Park Drive, Mount Pleasant, NC 28124 8590 Park Drive, Mount Pleasant, NC 28124
Current Mailing Address Current Street Address
Mount Pleasant NC 28124 Mount Pleasant NC 28124
City State Zip City State Zip
10. Deed Book No. Page No. 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 orif the landowner(s) is
an individual(s), the namefs) of the owner(s) may be listed as the financially responsible party(ies).
Town of Mount Pleasant,
(Randy Holloway, Town Manager)
Company Name
8590 Park Drive
Current Mailing Address
Mount Pleasant NC
City State
[e-mail]
E-mail Address
8590 Park Drive
Current Street Address
28124 Mount Pleasant
Zip City
Phone: Office # (7041-436-9803 Mobile #
NC 28124
State Zip
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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #

Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Dolan Cauble and Sandra Cauble
Name
1489 C Street
Current Mailing Address
Phone: Office #
1489 C Street
Current Street Address
Mobile #
Mt. Pleasant NC 28124 Mt. Pleasant NC 28124
City State Zip City State Zip
Deed Book No.9094 Page No.0178 Provide a copy of the most current deed.
Landowner 3 of Record:
Thomas Robb and Debra Robb
Name
8875 East Franklin Street
Current Mailing Address
Phone: Office #
8875 East Franklin Street
Current Street Address
Mobile #
Mt. Pleasant NC 28124 Mt. Pleasant NC 28124
City State Zip City State Zip
Deed Book No.1741 Page No 0302 Provide a copy of the most current deed.
Landowner 4 of Record:
Eric Gordon Boulware
Name
2904 Southwest Blvd
Current Mailing Address
Phone: Office #
8889 East Franklin Street
Current Street Address
Mobile #
Charlotte NC 28216 Mount Pleasant NC 28124
City State Zip City State Zip
Deed Book No.10885 Page No.0036 Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Current Mailing Address
City State Zip
Phone: Office #
Current Street Address
City
State
Mobile #
Zip

(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 Certificate of Assumed Name.
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.
Randy Holloway Town Manager
Type or print name Title or A7,:2
rity
s 62a
Signatur Date
I, AntC , a Notary Public of the County of OAba�
State of North Carolina, hereby certify that V1 0 116 W41L appeared personally
before me this day and being duly sworn acknowledgeb that the above form was executed by him/her.
Witness my hand and notarial seal, this of J day of , 20 0� a
Amy C Schuenernan (�� (�
NOTARY PUBLIC Notary
Cirrus County r�
North Carolina
M My commission expires
y Commission Expires January 19, 2027