NCC241508_FRO Submitted_20240517

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.)
P1art. Project Name Waxhaw Volunteer Fire Dept.
2. Location of land-disturbing activity: County Union City or Township Waxhaw
Highway/Street Waxhaw Creek Road Latitude 34d51'54.07"N Longitude 80d46r17.51"W
3. Approximate date land-disturbing activity will commence:December 1 , 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.31 AC
6. Amount of fee enclosed: $ 400'00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac= $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name QGD<=r'T E-mailVe.r,, Address r L�e. .�,r �yC' wc..x t.✓✓r'd
Telephone [phone] Cell# Fax# -
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Waxhaw Community Volunteer Fire Department and Rescue Squad,Inc. 704-843-4001 —
Name Telephone Fax Number
3500 Waxhaw Parkway 3500 Waxhaw Parkway
Current Mailing Address Current Street Address
Waxhaw, NC 28173 Waxhaw, NC 28173
City State Zip City State Zip
10. Deed Book No.7683 Page No.81 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.
Waxhaw Community Volunteer Fire Departpment and Rescue Squad,Inc.
Name E-mail Address
3500 Waxhaw Parkway 3500 Waxhaw Parkway
Current Mailing Address Current Street Address
Waxhaw, NC 28173 Waxhaw, NC 28173
City State Zip City State Zip
Telephone [phone] Fax Number

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Robert Kennedy [e-mail]
Name of Registered Agent E-mail Address
3500 Waxhaw Parkway 3500 Waxhaw Parkway
Current Mailing Address Current Street Address
Waxhaw, NC 28173 Waxhaw, NC 28173
City State Zip City State Zip
Telephone [phone] Fax Number 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.
2e� erg { —e,5 Z�✓\Y
Type or int name Title or Authority
L----- _//
? !!) I)C?
Signature Date
I, SP'�rc p (.,UKG'(-vl k , a Notary Public of the County of 6„,
State of North Carolina, hereby certify that Q.6')0-4 K "` appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this '' day of 1 , 20 `Lr
JANE A. BLACKHAM . A P --
NOTARY PUBLIC Notary
union county
Seal unionNotrh Carotin zt;�u ) �-� Li,
My commission expires
My Commission Expires