NCC241574_FRO Submitted_20240523

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 Union Street Improvements
2. Location of land-disturbing activity: County: Cabarrus City or Township: Concord
Highway/Street Union Street Latitude 35d24'38.54" N Longitude 80d34'52.41W
3. Approximate date land-disturbing activity will commence: June 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.5
6. Amount of fee enclosed: $ 260.00 . 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
8. Person to`contact should erosion and sediment control issues arise during land-disturbing activity:
Name J0SePt1 212EE, E-mail Address 3bnu e-Seth 0...m.410 140<<•co -.
Telephone 0t SZUI 0'L Cell# 10q (os7 Fax# VOt/cZZ 5494
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Concord 704-920-5555
Name Telephone Fax Number
35 Cabarrus Ave W 35 Cabarrus Ave W
Current Mailing Address Current Street Address
Concord, NC 28025 Concord, NC 28025
City State Zip City State Zip
10. Deed Book No: NA/Public ROW SURVEY PROVIDED 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.
SEAL-IkA a' rfoceder CQIQP. _Aso 6u_e.SPAlara Con Cfort • core
•f'•0e (009 I� Address €
Current Mailing Address Current Street Address
(I�1014,4D 241 itapilt. rtc- 2/31 bri
City State Zip City State Zip

Telephone 104 . 2ZI I t1- Fax Number ibq cn. sti9q
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
JASonl a-Arai bi44r
Type o- int name Title or Authority
ae" 51,
Si atu Date
I, x\ \nV l 10 1► Q.\I , a Notary Public of the County of C 06Y`'US
State of North Carolina, hereby certify that JAStri b -- appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my
•''handt. n aO•af'd notarial seal, this IS*" day of 1Y I , 20 Z(
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111
` ' tary
= My commission expires
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