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.