NCC241365_FRO Submitted_20240516

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
07.06 EROSION CONTROL FORMS AND CHECKLISTS
07.06.01 EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
No person may initiate any land-disturbing activity as defined in Chapter 158 of the Monroe City Code prior to
completion of this form,and an applicable and acceptable erosion and sedimentation control plan has been approved by
the City of Monroe Engineering Department. (Please type or print)
Part I
1. Name of Project RaceTrac - Monroe
2. Address where land disturbing activity will take place 4060 W Hwy 74, Monroe NC
3. Approximate date disturbing activity will commence 04/01/2p24
4. Purpose of development(residential, commercial,industrial, etc.) Commercial
5. Total acreage of land to be disturbed or uncovered 5.0 ae
6. Amount of fee enclosed(fee will be the amount of current policies per acre multiplied by the total number
of acres or any part of an acre from number 5. i.e. 7.28 acres equals 8 acres.) $1000
7. Agent to contact should sediment control issues arise during land disturbing activity
Name Robert Wingate 919-287-0798
Phone
8. Landowner(s)of Record(use blank page to list additional owners)
Name Tyson Land Investments, LLC Name
Mailing Address2593 W Roosevelt Blvd Mailing Address _
Ste 201, Monroe, NC 28110
Street Address 2593 W Roosevelt Blvd Street Address
Ste 201, Monroe, NC 28110
Phone n/a - - Phone
Fax n/a
Fax
9. Indicate Book and Page where deed of the property where land disturbing activity will take place is recorded
(use blank page to list additional owners)
Book 7088 Book
Page 779 - - Page
10. Tax Map Parcel Number where land disturbing activity will take place 0933 --6030__ B01
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part II
l. Person(s)or firm(s)who are financially responsible for this land disturbing activity(use blank page to list
additional owners)
Name - RaceTrac, Inc Name
Mailing Address_ 200 Galleria Parkway SE Mailing Address
Ste 900, Atlanta GA 30339
15720 Brixham Ave.
Street Address Street Address
Ste 300, Charlotte, NC 28277
Phone [phone] Phone
Fax Fax
2. A)If the Financially Responsible Party is not a resident of North Carolina,give name and address of a North
Carolina Agent Corporate Creations Network, Inc.
Name of Registered Agent
Mailing Address
15720 Brixham Ave Ste 300, Charlotte NC 28277
Street address City State Zip
Phone [phone] Email n/a _ Fax n/a
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 the name and street address of the Registered Agent:
Name of Registered Agent
Mailing Address
Street address City State Zip
Phone Email Fax
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath. I agree to provide corrected information should there be any change in the information provided
herein.(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 authority to execute instruments
for the financially responsible person)
Type or Print N Justen Giambalvo Vice President
Title -
Signature Date 0 7 / 17 / ZOZ'-1
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�/i �UNTr(, 0% Division 07
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