NCC240761_FRO Submitted_20240410

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Town Center Roadway Connection and Davis Creek Greenway Project
"If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
N/A
2. Location of land-disturbing activity: County Cabarrus City or Township Harrisburg
Hagler Street 35.3250 -80.6418
Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: February 1 , 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Transportation
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.2
6. Amount of fee enclosed: $300 . 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❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mallory Hodgson E-mail Address [e-mail]
Phone: Office# 704-206-8779 Mobile# N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HARRISBURG TOWN CENTER COMMERCIAL PROP OWNERS ASSOC N/A N/A
Name Phone: Office# Mobile#
4350 MAIN ST STE 220 N/A
Current Mailing Address Current Street Address
HARRISBURG, NC 28075 N/A
City State Zip City State Zip
10. Deed Book No. 9479 Page No. 0190 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)may be listed as the financially responsible party(ies).
Town of Harrisburg [e-mail]
Company Name E-mail Address
P.O. Box 100 4100 Main St, Suite 101
Current Mailing Address Current Street Address
Harrisburg, NC 28075 Harrisburg, NC 28075
City State Zip City State Zip
Phone: Office# 704-455-5614 Mobile# N/A
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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.
N/A
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.
Mallory Hodgson Director of Public Works
Type or print name Title or Authority
U (t12c0/2u23
ignatureu Date
I, Ski lL L 1rfte , a Notary Public of the County of Ca�c�r u.5 V
y I
State of North Carolina, hereby certify that l' Od10U 4-0At Son 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 a ID day of uirie , 20 a
11,1
0�lY'l P-/�
otary
Nor r),publ►
Meckle c
= (�,
_My Co m 9 County = My commission expires -'l-1,(A.as
mission Expires
y -r-a
�O F :

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:
HARRISBURG TOWN CTR RESIDENTAL PROPERTY OWNERS ASSOC INC N/A N/A
Name Phone: Office# Mobile#
C/O CUSICK COMMUNITY MGMT N/A
Current Mailing Address Current Street Address
CHARLOTTE, NC 28226 N/A
City State Zip City State Zip
Deed Book No. 6825 Page No. 0160 Provide a copy of the most current deed.
Landowner 3 of Record:
L&S LLC N/A N/A
Name Phone: Office# Mobile#
18725 E GALE AVE STE 250 3650 RUCKUS RD
Current Mailing Address Current Street Address
CITY OF INDUSTRY, CA 91748 HARRISBURG NC 28075
City State Zip City State Zip
Deed Book No. 12908 Page No. 0168 Provide a copy of the most current deed.
Landowner 4 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 5 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A N/A
Company 2 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 3 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 4 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 5 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
N/A N/A
Phone: Office# Mobile#