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HomeMy WebLinkAboutNCC232292_FRO Submitted_20230801 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 N/A in the blank.) Part A. 1. Project Name 12" Public Sewer Extension Phase 2 2. Location of land-disturbing activity: County Cabarrus City or Township Concord New Town Way 35.372536 -80.636112 Highway/Street Latltude(decimal degrees) Longitude(decimal degrees) 3. Approximate date land-disturbing activity will commence:January 2023 Public Sewer Construction 4. Purpose of development(residential, commercial, industrial, institutional, etc.): 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):9.30 6. Amount of fee enclosed: $ 1000.00 . 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 ❑x No 0 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Sue Hyde E-mail Address hydes@concordnc.gov Phone: Office# 704-920-5401 Mobile# 9. Landowner(s)of Record (attach accompanied page to list additional owners): Bootsmeade LeaseCo LLC 704-547-4880 Name Phone: Office# Mobile# 1717 S. Boulder Ave, STE 400 1717 S. Boulder Ave, STE 400 Current Mailing Address Current Street Address Tulsa OK 74119 Tulsa OK 74119 City State Zip City State Zip 10. Deed Book No. 1 1179 Page No. 0099 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 or if the landowner(s)is an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies). City of Concord hydes@concordnc.gov Company Name E-mail Address P.O. Box 308 Alfred M.Brown Operations Center 635 Alfred Brown Jr Court SW Current Mailing Address Current Street Address Concord NC 28206 Concord NC 28206 City State Zip City State Zip Phone: Office# 704-920-5401 Mobile# 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# 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. Lloyd Wm. Payne, Jr. City Manager Type or print name Title or Authority c-r-aturei Date I, á,' ,e/ ip464 f , a Notary Public of the County of 474./a41..... State of North Carolina, hereby certify that /P'7I /VM• ���/k, appeared personally before me this day and being duly sworn acknowledged that the a ove form was executed by him/her. Witness my hand and notarial seal, this grit-day of AIVII I4 V , 20 '- � T ' s ., Notary oA 9�My commission expires O— �o,. AUBL‘G 'O Continued from Items 9 & 10 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: CV NLA II LP Name Phone: Office# Mobile# 3025 New Town Way 3025 New Town Way Current Mailing Address Current Street Address Concord NC 28027 Concord NC 28027 City State Zip City State Zip Deed Book No. 13905 Page No.0167 Provide a copy of the most current deed. Landowner 3 of Record: RRB BEVERAGE OPERATIONS INC Name Phone: Office# Mobile# 10501 N Reems Road 10501 N Reems Road Current Mailing Address Current Street Address Waddell AZ 85355 Waddell AZ 85355 City State Zip City State Zip Deed Book No. 15353 Page No.0237 Provide a copy of the most current deed. Landowner 4 of Record: GOLDENHOME INTERNATIONAL INC Name Phone: Office# Mobile# 400 Agpar Dr STE A 400 Agpar Dr STE A Current Mailing Address Current Street Address Somerset NJ 08873 Somerset NJ 08873 City State Zip City State Zip Deed Book No. 14136 Page No.0072 Provide a copy of the most current deed. Landowner 5 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.