NCC242359_FRO Submitted_20240819

Check if this project is ARPA-funded ❑
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 Six Mile Tributary Wastewater Project
*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 Mecldenburg City or Township Charlotte
Southhampton
Highway/Street Commons Dr. Latitude(decimal degrees)35.023806 Longitude(decimal degrees)-80.830516
3. Approximate date land-disturbing activity will commence: 2nd Quarter 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Existing sewer replacement
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.88 Acres
6. Amount of fee enclosed: $ 500.00 . 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jason Marshall E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mecldenburg County
Name Phone: Office# Mobile#
600 East Fourth Street
Current Mailing Address Current Street Address
Charlotte,NC 28202
City State Zip City State Zip
10. Deed Book No. 29434 Page No. 317 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).
Charlotte Water [e-mail]
Company Name E-mail Address
5100 Brookshire Blvd.
Current Mailing Address Current Street Address
Charlotte,NC 28216
City State Zip City State Zip
Phone: Office# 704-336-1015 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:
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)
(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)

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

(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.
Keri Cantrell Chief Engineer
Type or print name Title or Authority
Signature Date
I,0)aYaeZ L /�t',(/�� , a Notary Public of the County of,//7f�,J/bit/ I
V
State of North Carolina, hereby certify that / ri ( .61n//// appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this , day of t4a/d) , 20 Zj
lzita -1 -Or
.�',,,,e.ckt ESE a
y
GaP�Z My commission expires / Olk
..?Yber 12. ;(l-

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Ardrey Crest Homeowners Association,Inc
Name Phone: Office# Mobile#
PO Box 11906
Current Mailing Address Current Street Address
Charlotte,NC 28220
City State Zip City State Zip
Deed Book No. 25678 Page No. 441 Provide a copy of the most current deed.
Landowner 3 of Record:
Ardrey Chase Homeowners Association,Inc
Name Phone: Office# Mobile#
3030 Latrobe Drive
Current Mailing Address Current Street Address
Charlotte,NC 28211
City State Zip City State Zip
Deed Book No. 26813 Page No. 194 Provide a copy of the most current deed.
Landowner 4 of Record:
Oxford/Cambridge Homeowners Association
Name Phone: Office# Mobile#
5350 Seventy Seven Center Dr.,Unit 100
Current Mailing Address Current Street Address
Charlotte,NC 28217
City State Zip City State, Zip
Deed Book No. 26685 Page No. 988 Provide a copy of the most current deed.
Landowner 5 of Record:
Noralba Mendoza Espinoza
Name Phone: Office# Mobile#
17316 Commons Crossing Dr.
Current Mailing Address Current Street Address
Charlotte,NC 28277
City State Zip City State Zip
Deed Book No. 33832 Page No. 066 Provide a copy of the most current deed.