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HomeMy WebLinkAboutNCC243243_FRO Submitted_20241023 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: HERC Rental *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). Is Project ARPA Funded ARPA Project Name ARPA Project# No N/A N/A 2. Location of land-disturbing activity: County: Union City or Township: Indian Trail Highway/Street: Technology Drived Latitude: 35.070811 Longitude:-80.645787 3. Approximate date land-disturbing activity will commence: 9/1/2024 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.50 6. 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). 7. Has an erosion and sediment control plan been filed? No 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name: Van Boyett E-mail Address: van@boyettproperties.com Phone: 8646750075 Mobile: 8649010927 9. Landowner(s)of Record: Landowner(s) of Record Name Email Business Phone Mobile Phone Dorothy Hall Properties, LLC Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 1065 East Charlotte NC 28204 1065 East Charlotte NC 28204 Morehead Street Morehead Street Name Email Business Phone Mobile Phone Pebble Creek Associates Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 1318-F Central Charlotte NC 28025 1318-F Central Charlotte NC 28025 Avenue Avenue Name Email Business Phone Mobile Phone Anne Scott Hatcher Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip _ 7525 Valleybrook Charlotte NC 28270 7525 Valleybrook Charlotte NC 28270 Road Road 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). Primary Financially Responsible Party Company Name Email Business Phone Mobile Phone Technology Boulevard Indian Trail, LLC van@boyettproperties.com Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 1325 Miller Road Greenville SC 29607 176 Mine Lake Raleigh NC 27615 Court Additional Financially Responsible Parties 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: Registered Agent Information Name Email Business Phone Mobile Phone NC Corporate Connection, Inc. krozar@nccorporate.com Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 176 Mine Lake Raleigh NC 27615 176 Mine Lake Raleigh NC 27615 Court Court (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: North Carolina Agent Information Name Email Business Phone Mobile Phone Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip Engineering/Consulting Firm Information Name Email Business Phone Mobile Phone Craig Berwick cberwick@seamonwhiteside.com 9198302606 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 230 W Peterson Charlotte NC 28217 230 W Peterson Charlotte NC 28217 Drive Drive Additional Details 1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water 2. Was Express Review Requested: No 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.