NCC241942_FRO Submitted_20240626

Check if this project is ARPA-funded El
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 Atrium Union West Offsite Roadway Phase 2
*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).
2. Location of land-disturbing activity: County Union County City or Township Stallings
Highway/Street Stallings Road Latitude(decimal degrees)35.092332 Longitude(decimal degrees)-80.684064
3. Approximate date land-disturbing activity will commence:08/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Hospital
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.93
6. Amount of fee enclosed: $200.00. 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 ❑ Enclosed El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jeremy Hughes E-mail Address Jeremy.hughes(a�atriumhelath.orq
Phone: Office#704-591-7212 Mobile#[phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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).
The Charlotte Mecklenburg Hospital Authority(CHS) [e-mail]
Company Name E-mail Address
PO Box 32861 9401 Arrowpoint BLVD., Office 306
Current Mailing Address Current Street Address
Charlotte NC 28232 Charlotte NC 28273
City State Zip City State Zip
Phone: Office# 704-667-9482 Mobile#
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:
C T Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Suite 200 160 Mine Lake Ct, Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27615-6417 Raleigh, NC 27615-6417
City State Zip City State Zip
Phone: Office# Mobile#
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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.
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.
Jamey Basinger Director of Planning, Design, & Construction
Type or print name Title or Authority
�� '. a 2.023
S ature Date
�I1 qq
I, nn I`� I()i SOP 0,n , a Notary Public of the County of N (f 1aLr
State of North Carolina, hereby certify that ,)Gi.dVl QL-) appeared personally
before me this day and being duly sworn acknowledged-that the abovb form was executed by him/her.
Witness my hand and notarial seal, this 7 day of JvI,V,e, , 2093
Notary
My commission expires 1.0 — (O Ao
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sn€.d3' `AW ?�

10. Landowner(s) of Record (attach accompanied page to list additional owners):
H&J PROPERITES OF UNION COUNTY LLC 704-821-1946 N/A
Name Telephone Fax Number
1129 FLOWE DRIVE 1148 Stallings Road
Current Mailing Address Current Street Address
Stallings NC 28104 Stallings NC 28104
City State Zip City State Zip
11. Deed Book No. 5730 Page No. 304 Provide a copy of the most current deed.
12. Landowner(s)of Record (attach accompanied page to list additional owners):
H&J PROPERITES OF UNION COUNTY LLC 704-821-1946 N/A
Name Telephone Fax Number
1129 FLOWE DRIVE 1146 Stallings Road
Current Mailing Address Current Street Address
Stallings NC 28104 Stallings NC 28104
City State Zip City State Zip
13. Deed Book No. 3894 Page No. 358 Provide a copy of the most current deed.
14. Landowner(s)of Record (attach accompanied page to list additional owners):
STALLINGS UNITED METHODIST CHURCH 704-821-8820 N/A
Name Telephone Fax Number
1115 STALLINGS ROAD 0 Stallings Road
Current Mailing Address Current Street Address
Matthews NC 28104 Stallings NC 28104
City State Zip City State Zip
15. Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
16. Landowner(s)of Record (attach accompanied page to list additional owners):
H&J PROPERITES OF UNION COUNTY LLC 704-821-1946 N/A
Name Telephone Fax Number
1129 FLOWE DRIVE 1142 Stallings Road
Current Mailing Address Current Street Address
Stallings NC 28104 Stallings NC 28104
City State Zip City State Zip
17. Deed Book No. 5424 Page No. 486 Provide a copy of the most current deed.
18. Landowner(s) of Record (attach accompanied page to list additional owners):
STALLINGS UNITED METHODIST CHURCH 704-821-8820 N/A
Name Telephone Fax Number
1115 STALLINGS ROAD 0 Stallings Road

Current Mailing Address Current Street Address
Matthews NC 28104 Stallings NC 28104
City State Zip. City State Zip
19. Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
20. Landowner(s) of Record (attach accompanied page to list additional owners):
Richard H Privette N/A N/A
Name Telephone Fax Number
5709 POPLIN RD. 3001 Smith Farm Road
Current Mailing Address Current Street Address
Indian Trail NC 28079 Matthews NC 28104
City State Zip City State Zip
21. Deed Book No. 1107 Page No. 607 Provide a copy of the most current deed.
22. Landowner(s)of Record (attach accompanied page to list additional owners):
H&J PROPERITES OF UNION COUNTY LLC N/A N/A
Name Telephone Fax Number
1129 FLOWE DR 30254 Smith Farm Rd
Current Mailing Address Current Street Address
Stallings NC 28104 Stallings NC 28104
City State Zip City State Zip
23. Deed Book No. 4733 Page No. 252 Provide a copy of the most current deed.
24. Landowner(s) of Record (attach accompanied page to list additional owners):
CEM CORPORATION 704-821-7015 N/A
Name Telephone Fax Number
3100 SMITH FARM RD. 1042 Stallings Road
Current Mailing Address Current Street Address
Matthews NC 28104 Stallings NC 28104
City State Zip City State Zip
25. Deed Book No. 4307 Page No. 620 Provide a copy of the most current deed.
26. Landowner(s)of Record (attach accompanied page to list additional owners):
CEM Property Management 704-821-7015 N/A
Name Telephone Fax Number
3100 SMITH FARM RD. 1020 Stallings Road
Current Mailing Address Current Street Address
Matthews NC 28104 Stallings NC 28104
City State Zip City State Zip

27. Deed Book No. 5224 Page No. 87 Provide a copy of the most current deed.
28. Landowner(s)of Record (attach accompanied page to list additional owners):
TOSOYEV, RAKHIM& 973-356-7604 N/A
SPOUSE FAKHIMA TOSOYEVA
Name Telephone Fax Number
5023 MAGNA LN. 0 Stallings Road
Current Mailing Address Current Street Address
Indian Trail NC 28079 Matthews NC 28104
City State Zip City State Zip
29. Deed Book No. 7310 Page No. 109 Provide a copy of the most current deed.
30. Landowner(s)of Record (attach accompanied page to list additional owners):
BERRY GLOBAL FILMS, LLC 704-821-9233 N/A
(FKAAEP INDUSTRIES INC)
Name Telephone Fax Number
6 CONCOURSE PKWY, STE. 2000 303 Seaboard Drive
Current Mailing Address Current Street Address
Atlanta GA 30328 Matthews NC 28104
City State Zip City State Zip
31. Deed Book No. 6939 Page No. 460 Provide a copy of the most current deed.
32. Landowner(s)of Record (attach accompanied page to list additional owners):
ALADAL LLC 704-821-9229 N/A
Name Telephone Fax Number
105 SEABOARD DR. 0 Gribble Road
Current Mailing Address Current Street Address
Matthews NC 28104 Matthews NC 28104
City State Zip City State Zip
P. O. BOX 1885
Current Mailing Address
Matthews NC 28106-1885
City State Zip
33. Deed Book No. 1484 Page No. 349 Provide a copy of the most current deed.