NCC232481_FRO Submitted_20230816

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.)
Part A.
1. Project Name Field Operations Zone 2 Facility Vacuum Truck Receiving Station
2. Location of land-disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street_General Commerce Dr Latitude 35° 15' 34" Longitude -80° 46' 07"
3. Approximate date land-disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_ Municipal
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.0
6. Amount of fee enclosed: $ 100 . 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).
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian D. Pate E-mail Address brian.pate@_charlottenc.gov
Telephone [phone] Cell # 980-721-0229 Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners): SEE ATTACHED
Name Telephone Fax Number
Current Mailing Address Current Street Address
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) 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.
City of Charlotte, Joseph C. Wilson cwilsonci.charlotte.nc.us
Name E-mail Address
5100 Brookshire Blvd. 5100 Brookshire Blvd.
Current Mailing Address Current Street Address
Charlotte NC 28216 Charlotte NC 28216
City State Zip City State Zip
Telephone [phone] Fax Number 704.398.9180

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:
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Name -E mail Address
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Current Mailing Address Current Street Address
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City State Zip City State Zip
Telephone ( _---- Fax Number t,FS 1A—
(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:
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Name of
Registered gent E-mail Address
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Current Mailing Addr ss Current Street Address
Cit State Zi Cit State Zip Y p Y
Telephone f' (r Fax Number fr-
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.
Joseph C. Wilson Chief Engineer
Type 1 pri t name Title or Authority
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Sign a Date
I, )(At H "*t, . .�� 4 , a Notary Public of the County of
State of North Carolina, hereby certify that �® eh C . 1 h appeared
personally before me this day and being duly sw.rn acknowledged that the above form was
executed by him.
Witness my illila d notarial seal, this tla day of 3 i s , 20
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