NCC241718_FRO Submitted_20240607

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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 Crooked Creek Trunk Sewer Phase I I Interceptor Improvements
2. Location of land-disturbing activity: County Union City or Township Indian Trail
Highway/Street Sardis Church Rd Latitude 35.068953 Longitude-80.633689
3. Approximate date land-disturbing activity will commence:N/A
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Municipal Sewer
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10.16 ac
6. Amount of fee enclosed: $3,100 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
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 Thomas Mann-CIP Program Manager
email Addreoothomas.mannAUnioncountync.gov
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Various, see attached sheet
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
See attached sheet See attached sheet
10. Deed Book No. 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.
Union County Public Works
Name E-mail Address
5500 N Main�S
rrent dt Ste 615 500 N Main St Ste 615 •
Malling dress Current Street Address
Monroe NC 28112 Monroe NC 28112
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:
N/A
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:
Thomas Mann
Name of Registered Agent E-mail Address
500 North Main Street,Suite 615 500 North Main Street,Suite 615
Current Mailing Address Current Street Address
Monroe NC 28112 Monroe NC 28112
City State Zip City State Zip
Telephone [phone] Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Brown and Caldwell [e-mail]
Engineering Firm or other consultant E-mail Address
Keller Schnier 704.373.7141
Individual contact person (type or print) 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.
Thomas Mann CIP Program Manager
Type or print name Title or Authority
/'C. ram.- 2- 2-3- 22
Signature Date
I, . grt-5 rod , a Notary Public of the County of f,( ti v.--
State of North Carolina, hereby certify that i .,4.5 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 <2 3 - day of_i r A,- r , 20 Z Z
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�.•°•'•••®�p �' Notary
s •• Seal °e `,'%° s My Com�tlsslon Expires 10/7/2025
ar • ° l �moNsNxuo.�AW
OTARk b My commission expires 4L0�1t10
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PARCEL PIN OWNER PHYSICAL ADDRESS MAILING ADDRESS CITY STATE ZIPCODE DEED BOOK 1 DEED PAGE 1 DEED BOOK 2 DEED PAGE 2 DEED BOOK 3 DEED PAGE 3
1 7084385 FIRST-CITIZENS BANK&TRUST COMPANY 424 N INDIAN TRAIL RD P O BOX 27131 RALEIGH NC 27611-7568 891 491 891 489 --- ---
2 7084412 L&J FISHER LLC 139 BUSINESS PARK DR PO BOX 307 INDIAN TRAIL NC 28079 4402 702 --- -- -- ---
3 7084586 FIRST CITIZENS BANK&TRUST COMPANY 0 POST OFFICE DR PO BOX 27568 RALEIGH NC 27611 4715 174 2028 163 1396 527
4 7084587 TRIPLE L HOLDINGS LLC 311 POST OFFICE DR 4004 WILLOW GREEN PL CHARLOTTE NC 28206 6365 23 2028 163 -- ---
07084588 02 2BAMF LLC 309 POST OFFICE DR 309 POST OFFICE DR INDIAN TRAIL NC 28079 1830 756 --- --- --- ---
07084588 03 2BAMF LLC 309 POST OFFICE DR 309 POST OFFICE DR INDIAN TRAIL NC 28079 1830 756 --- -- --- ---
07084588 04 2BAMF LLC 309 POST OFFICE DR 309 POST OFFICE DR INDIAN TRAIL NC 28079 3257 447 --- --- --- ---
07084588 05 2BAMF LLC 309 POST OFFICE DR 309 POST OFFICE DR INDIAN TRAIL NC 28079 3369 7 --- -- --- ---
07084588 06 RTC LANDHOLDINGS LLC 305 POST OFFICE DR 305-A POST OFFICE DR INDIAN TRAIL NC 28079-7671 6751 140 3326 144 --- ---
5 07084588 07 REYNOLDS LONNIE B 305 POST OFFICE DR 305 POST OFFICE DR STE B INDIAN TRAIL NC 28079-7809 3325 569 --- -- -- ---
07084588 08 OUTSIDE MECKLENBURG PROPERTIES LLC 305 POST OFFICE DR 3030 LATROBE DR CHARLOTTE NC 28211 7919 151 6274 53 5049 754
07084588 09 AMERICLAIMS INC 305 POST OFFICE DR 5509 SILVER CREEK DR WAXHAW NC 28173 5371 759 4380 852 4380 850
07084588 10 TENTEX ENERGY LLC 301 POST OFFICE DR 110 ASSOCIATES LN INDIAN TRAIL NC 28079 7243 233 3325 560 -- ---
07084588 11 TENTEX ENERGY LLC 301 POST OFFICE DR 110 ASSOCIATES LN INDIAN TRAIL NC 28079 7243 233 3325 560 -- ---
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07084588 13 TENTEX ENERGY LLC 301 POST OFFICE DR 110 ASSOCIATES LN INDIAN TRAIL NC 28079 7243 233 3325 560 --- ---
07084589 02 BREWER-BAUCOM PROPERTIES LLC 251 POST OFFICE DR P O BOX 769 MARSHVILLE NC 28103 3149 636 1751 119 --- ---
07084589 03 BREWER-BAUCOM PROPERTIES LLC 251 POST OFFICE DR P O BOX 769 MARSHVILLE NC 28103 3149 636 1751 119 -- ---
07084589 04 SPIVEY CHRIS 251 POST OFFICE DR PO BOX 2220 INDIAN TRAIL NC 28079 1653 396 --- --- --- ---
6 07084589 05 SPIVEY CHRIS 251 POST OFFICE DR PO BOX 2220 INDIAN TRAIL NC 28079 6803 570 3149 634 1883 440
07084589 06 LACE CONSTRUCTION INC 255 POST OFFICE DR 255 POST OFFICE DR STE A INDIAN TRAIL NC 28079 8181 71 5350 596 4143 427
07084589 07 TENTEX ENERGY LLC 255 POST OFFICE DR 110 ASSOCIATES LN INDIAN TRAIL NC 28079 6798 763 4143 427 1733 296
07084589 08 FREITAG PROPERTIES LLC 255 POST OFFICE DR 5509 SILVER CREEK DR WAXHAW NC 28173 5902 804 1733 296 --- ---
07084589 09 PGR CUSTOM HOMES LLC 255 POST OFFICE DR 10 KNIGHT ST GLENS FALLS NY 12801 4374 410 1733 296 --- ---
7 07105004A LIQUID MANAGEMENT LLC --- 231 POST OFFICE DR STE B-8 INDIAN TRAIL NC 28079-7678 --- --- --- --- --- ---
8 07105005D ELAN INDIAN TRAIL OWNER LLC 169 NELSON LEMMOND DR 521 E MOREHEAD ST STE 400 CHARLOTTE NC 28202 7657 333 7550 529 --- ---
9 07105005E SNYDER JANICE BIVENS LEMMOND HEIRS --- 324 BUBBLING WELL RD MATTHEWS NC 28105 --- --- --- --- --- ---
10 07111018A OSBORNE BEVERLY V 0 INDIAN TRAIL RD 4646 SHANNAMARA DR MATTHEWS NC 28104 1030 28 --- -- --- ---
11 071110181 DOUGLAS RONALD W 115 BROOKE LN PO BOX 504 INDIAN TRAIL NC 28079-0504 -- --- --- --- --- ---
12 07111018K PAPPAS MIKE GUS ET AL 0 WAXHAW INDIAN TRAIL RD 323 SKYECROFT WAY WAXHAW NC 28173 -- --- --- -- --- ---
13 7084328 LIQUID MANAGEMENT LLC 319 PLYLER RD 231 POST OFFICE DR STE B8 INDIAN TRAIL NC 28079 7235 85 --- --- --- ---
14 7084340 HARNETT SARA LEE 14520 E INDEPENDENCE BLVD 4 LAKE COMO CT GREENVILLE SC 29609-3063 W14E 256 6436 746 --- ---
15 7084380 ALLISON PAUL 275 UNIONVILLE INDIAN TRAIL RD 275 UNIONVILLE-INDIAN TRAIL RD INDIAN TRAIL NC 28079-9509 4572 153 --- --- --- ---
16 7084395 M MONTGOMERY PROPERTIES LLC 115 CORPORATE BLVD 1015 E WESTINGHOUSE BLVD CHARLOTTE NC 28273 4960 716 4933 414 1300 262
17 7084400 PARTAY LLC 132 CORPORATE BLVD 132 CORPORATE BLVD INDIAN TRAIL NC 28079 7608 319 --- --- --- ---
18 7084407 KNIGHT SUSANNAH CARR SET AL 107 BUSINESS PARK DR PO BOX 470067 CHARLOTTE NC 28247 5259 372 5259 372 --- ---
19 7084408 3 STAR ENTERPRISES LLC 115 BUSINESS PARK DR 5932 WHITE STORE RD WINGATE NC 28174 1430 372 --- --- --- ---
20 7084409 D'APRILE PROPERTIES LLC 0 BUSINESS PARK DR P O BOX 328 INDIAN TRAIL NC 28079-0328 1104 8 --- -- --- ---
21 7084410 D'APRILE PROPERTIES LLC 131 BUSINESS PARK DR P O BOX 328 INDIAN TRAIL NC 28079-0328 1104 8 --- --- --- ---
22 07084328A ASPEN ASSET GROUP LLC 0 HWY 74 P O BOX 1077 MATTHEWS NC 28106-1077 989 675 989 672 --- ---
23 07084333E LIDL US OPERATIONS LLC 14600 E INDEPENDENCE BLVD 35005 CLARK ST ARLINGTON VA 22202 6913 124 --- --- --- ---
24 07084380A RIVERSIDE CONCRETE INC 287 UNIONVILLE INDIAN TRAIL RD 3520 PHIFER RD WINGATE NC 28174 7475 205 2049 751 --- ---
25 070843808 BRASWELL JOHN T 283 UNIONVILLE INDIAN TRAIL RD 2533 MT HARMONY CHURCH RD MATTHEWS NC 28105-4107 5137 727 --- --- --- ---
26 07084405A THOMPSON REALTY INVESTMENTS LL 14500 W HWY 74 2334 JEFFERSON AVE GASTONIA NC 28056 937 882 --- -- --- ---
27 07084405G 215 ROWELL LLC 0 W HWY 74 4614 WILGROVE MINT HILL RD CHARLOTTE NC 28227 7716 198 6223 513 6115 909
28 7066758 PEBBLE CREEK ASSOCIATES O TECHNOLOGY BLVD 1318F CENTRAL AVE CHARLOTTE NC 28205 --- --- --- -- --- ---
29 7066759 PEBBLE CREEK ASSOCIATES O TECHNOLOGY BLVD 1318F CENTRAL AVE CHARLOTTE NC 28205 --- --- --- --- --- ---
30 7066760 PEBBLE CREEK ASSOCIATES 1105 TECHNOLOGY BLVD 1318F CENTRAL AVE CHARLOTTE NC 28205 --- --- --- --- --- ---
31 7066761 PEBBLE CREEK ASSOCIATES 1101 TECHNOLOGY BLVD 1318F CENTRAL AVE CHARLOTTE NC 28205 --- --- --- --- --- ---
32 7066762 PEBBLE CREEK ASSOCIATES 1025 TECHNOLOGY BLVD 1318F CENTRAL AVE CHARLOTTE NC 28205 -- --- --- -- --- ---
33 7066763 PEBBLE CREEK ASSOCIATES 1021 TECHNOLOGY BLVD 1318F CENTRAL AVE CHARLOTTE NC 28205 --- --- --- --- --- ---
34 7066764 ZALAQUETT EDDIE 1017 TECHNOLOGY BLVD 3064 ANCESTRY CIRCLE MATTHEWS NC 28104-8634 5504 760 1713 513 1353 364
35 7066765 HELMS STEVE 1013 TECHNOLOGY BLVD 1500 EMERALD LAKE DR MATTHEWS NC 28104 7946 308 1218 742 --- ---
36 7087006 LR&FR LLC 0 HWY 74 P O BOX 267 INDIAN TRAIL NC 28079 3409 898 --- -- --- ---
37 07066017A SYNDICATE HOLDINGS NC LLC 1009 TECHNOLOGY BLVD 115 S MAIN ST WASHINGTON IL 61571 8055 691 1199 637 --- ---
38 07084320E UNION COUNTY ADMINISTRATIVE SERVICES OTYSON RD 500 N MAIN ST STE 709 MONROE NC 28112 -- --- --- -- --- ---
39 07084325A UNION COUNTY WIN-WIN LLC-ATTN:MCA 14700 E INDEPENDENCE BLVD 309 POST OFFICE DRIVE INDIAN TRAIL NC 28079-7671 4156 332 1796 792 1222 253
40 07084325B PLYLER JACK HARVEY 0 HWY 74 310 PLYLER RD INDIAN TRAIL NC 28079 -- --- --- -- -- ---
41 7066092 ASHE CROFT HOMEOWNER'S-ATTN:STEVE DORMADY 0 COMPTON CT PO BOX 37109 CHARLOTTE NC 28237-7109 -- --- --- --- -- ---
42 7066720 AMADOR BERTHA ALICIA 1723 COTTAGE CREEK RD 1723 COTTAGE CREEK RD INDIAN TRAIL NC 28079 6291 266 6103 754 5109 821
43 7066721 TASSE CHERYL ANN 1734 COTTAGE CREEK RD 1734 COTTAGE CREEK RD INDIAN TRAIL NC 28079 5909 542 5909 542 4546 202
44 7066722 BADILLO DORA A 1730 COTTAGE CREEK RD 1730 COTTAGE CREEK DR INDIAN TRAIL NC 28079-9467 3947 1 1295 178 1249 131
45 7066771 RIVERSIDE PROPERTY MANAGEMENT LLC OTECHNOLOGY BLVD 3520 PHIFER DR WINGATE NC 28174 6657 361 3362 627 1563 455
46 7066772 CHARLOTTE VAN AND STORAGE CO INC 0 HWY 74 P O BOX 2466 LANCASTER SC 29721 8184 584 1499 780 -- ---
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48 7066774 PEBBLE CREEK ASSOCIATES 0 HWY 74 1318F CENTRAL AVE CHARLOTTE NC 28205 -- --- --- -- -- ---
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50 7066776 ANDERSON KRISTY W 1221 TECHNOLOGY BLVD 16011 A LANCASTER HWY 337 CHARLOTTE NC 28277 8142 765 3936 419 3040 196
51 7066992 TECHNOLOGY DRIVE 19 REALTY LLC 0000 TECHNOLOGY DR 2525 PROVIDENCE HILLS DR MATTHEWS NC 28105 8066 394 --- --- --- ---
52 07066013E MAR FLAGSTONE LLC 1103 FLAGSTONE LN PO BOX 56607 ATLANTA GA 30343 6499 612 5891 372 4086 599
53 070660158 UNION COUNTY ADMINISTRATIVE SERVICES 4015 SARDIS CHURCH RD 500 N MAIN ST STE 709 MONROE NC 28112 --- --- --- --- --- ---