NCC230728_FRO Submitted_20230320

FINANCIAL, RESPONSIBILITYIOWNERSHIP 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.
1
2.
3.
4.
5.
6.
7.
8.
tijl
Project Name: Steelpoint
Location of land -disturbing activity: County: Union City or Township: Stallings
Highway/Street: Union West Bvl Latitude(decimaldegrees) 35.05.36 Longitude(decimaldegrees) 80.39.44
Approximate date land -disturbing activity will commence: March 1, 2023
Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.0
Amount of fee enclosed: $ 1400. 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Robert Holland E-mail Address: [e-mail]
Phone: [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Primax Properties LLC
Name Phone: [phone]
1100 East Morehead Street Charlotte, NC 28204
Current Mailing Address
City
State Zip City
State
10. Deed Book No. 8566 Page No. 0499 Provide a copy of the most current deed.
Zip

Part B.
I. 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 names) of the owner(s) may be listed as the financially responsible party(ios).
Primax Properties LLC
Company Name
1100 East Morehead Street
Current Mailing Address
[e-mail]
E-mail Address
1100 East Morehead Street
Current Street Address
Charlotte NC 28204 Charlotte NC 28204
City State Zip City State Zip
Phone: Office # 704-344-8200 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:
William Se mour [e-mail]
Name of Registered Agent E-mail Address
1100 East Morehead Street 1100 East Morehead Street
Current Mailing Address Current Street Address
Charlotte NC 28204 Charlotte, NC 28204 _
City State Zip City State Zip
Phone: Office # 704-344-8200 Mobile # [phone]
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 #
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 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.
Robert Holland
Typ int a
Signature
_Project Manager
Title or Authority
3.�3�3
Date
I, f � li_ 4,� ­- , a Notary Public of the County of ate
State of North Carolina, hereby certify that c�,� �, ,<<4- o 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 1b*__ day of 20 Z3_
-IT E N �i.,� Notary
¢� 4e
N 0 T,q R Y My commission expires
_� p�$LIC 2�

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:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone_ Office # Mobile #
Current Mailing Address
Current Street Address
City
Deed Book No._
Landowner 5 of Record:
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed
to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #