SW3120102_Sediment Pollution_20120208

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION JC1J]fONTI,ROL'f} ACj1T /J
Y�k,IV ),60-0J
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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blanK.)
Part A.
Project Name AutoZone Stores, -Inc.— Indian Trail
2. Location of land -disturbing activity: County Union City or Township_Hemby Bridge
Highway/Street Idlewild Road Latitude N35-06'91" Longitude W80-38'04"
3. Approximate date land -disturbing activity will commence: March 2012
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.3
6. Amount of fee enclosed: $ 130.00 . The application fee of $65.00 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
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Wade Davis E-mail Address wade. davisPautozone.corn
Telephone [phone] Cell #
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Theodore Karres
Name Telephone Fax Number
442 Slairmore Drive
Current Mailing Address
Current Street Address
Charlotte NC 28211
City State Zip City State Zip
10. Deed Book No. RE A Page No. 177A Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
_AutoZone Development Corporation
Name
123 S. Front Street
Current Mailing Address
wade.davis(a autozone.com
E-mail Address
Current Street Address
_Memphis TN 38103_
City State Zip City State Zip
Telephone[phone] Fax Number, 901-495-8969