NCC231778_FRO Submitted_20230728

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.)
P1.art A.Project Name The Springs Business Park
2. Location of land-disturbing activity: County Cabarrus City or Township Concord
Highway/Street Pitts School Rd. Latitude N35°23'40.86" Longitude W80°24'55.87"
3. Approximate date land-disturbing activity will commence: March 1st, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.428
$100.00
6. Amount of fee enclosed: $500 . The application fee of $Cf.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 Dave Davis E-mail Address [e-mail]
Telephone Cell# [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Springs Business Park LLC
Name Telephone Fax Number
805 Trade Street NW, Suite 102 805 Trade Street NW, Suite 102
Current Mailing Address Current Street Address
Concord NC 28027 Concord NC 28027
City State Zip City State Zip
10. Deed Book No. 15276 Page No.0105 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.
Fortius Capital Partners [e-mail]
Name E-mail Address
805 Trade St NW STE 102 805 Trade St NW STE 102
Current Mailing Address Current Street Address
Concord NC 28027 Concord NC 28027
City State Zip City State Zip
Telephone[phone] Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Harris Morrison [e-mail]
Name of Registered Agent E-mail Address
805 Trade St NW Suite 102 805 Trade St NW Suite 102
Current Mailing Address Current Street Address
Concord NC 28027 Concord NC 28027
City State Zip City State Zip
Telephone [phone] Fax Number
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.
Harris Morrison °Ie
Type or print name Title or Auth
all` lit
Si ature Date
I, .`6 0. tAk , a Notary Public of the County of CO-v. iS
State of North Carolina, hereby certify that 144 0\13..,u2, _ 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 day of -kit7run.y , 203a
otary
() My commission expires`Kka. 13 `-I
1 •