NCC242696_FRO Submitted_20240830

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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM c
Soil Erosion and Sedimentation Control Ordinance NORTH C A R O L I N A
Instructions: No person shall initiate any land-disturbing activity on one or more acres, as covered in the Town of
Huntersville Soil Erosion and Sedimentation Control Ordinance,before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Huntersville. The Financially
Responsible Party will be on record as the party to accept any Notices of Violation or related documents for any non-
compliance of the Town of Huntersville Soil Erosion and Sedimentation Control Ordinance.If the Financially
Responsible Party resides out of state,a North Carolina agent must be assigned. All items on this form must be
filled out accurately and completely.
PART A-PROJECT AND LANDOWNER INFORMATION
1. Project name Everette Keith Logistics Park
2. Address of land-disturbing activity (number, street) 11226 Everette Keith Road
3. Approximate date land-disturbing activity will begin June 1, 2024
4. Purpose of development(Commercial, Residential, Industrial
•
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered 60.00
6. Total site acreage 60.21
7. Landowner(s) of Record. The names listed below must match the Deed(s).Attach a list of additional owners, if
applicable.
Note: If the landowner of record is not the person(s)firm(s),or Company's Financially Responsible Party,
as listed in Part B, item 1, a separate Letter of Consent, signed and dated by the Landowner of
Record, or their Authorized Agent,is required.
Landowner 1 of Record
Company Name Contact Name
If applicable
Mailing Address
Physical Address
IfPO Box listed above
Phone Email
Landowner 2 of Record
Company Name Contact Name
If applicable
Mailing Address
Physical Address
If PO Box listed above
Phone Email
8. Indicate the Deed Book and Page number the deed or instrument is filed. Attach a list of additional deeds if
applicable.
Deed Book Page Deed Book Page Deed Book Page
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 3

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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM ci
Soil Erosion and Sedimentation Control Ordinance NORTH C A R O L I N A
PART B - FRO AND NC REGISTERED AGENT
1. Person(s),firm(s)or Company who is/are financially responsible for this land-disturbing activity.
Financially Res'onsible Party
Company Name(if applicable) CHARLOTTE EVERETT Contact Name Michael Cain
KEITH ROAD IND
OWNER LLC
Mailing Address 2151 Hawkins St. Suite 1000 Charlotte NC 28023
Physical Address
If PO Box listed above _
Phone [phone] ( Email [e-mail]
2. If the Financially Responsible Party listed above does not reside in the state of North Carolina,they must
provide a designated North Carolina agent below. This agent must be registered with the NC Secretary of State.
North Carolina Agent for Financially Responsible Party
NC Registered Agent Name CT Corporation System Contact Name
Mailing Address 160 Mine Lake Ct Suite 200,Raleigh,NC 27615
Physical Address
If PO Box listed above
Phone [phone] ( Email l
3. (Optional)Additional contact familiar with the site,who understands the plans, and may represent the company.
Site Contact's Name Email
Phone: Office Phone:
Mobile
PART C - SIGNATURE WITNESSED BY A NOTARY PUBLIC
DO NOT SIGN THIS FORM UNTIL YOU ARE IN THE PRESENCE OF A NOTARY PUBLIC
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. If the
Financially Responsible Owner is not an individual, this form must be signed 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.
Printed Name Bill Simerville Title r Authority Managing Director
Wet-Ink Signature Date 4/24/24
I Claire A. Scott a Nola,y Public of the County o/ Mecklenburg
State of North Carolina , hereby certify that Bill Simerville personally
appeared 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 24th day of April , 20 24
Rev. 8/2022 Page 2 of 3

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
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Soil Erosion and Sedimentation Control Ordinance NORTH C A R O L r N A
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Rev. 8/2022 Page 3 of 3