NCC215275_FRO Submitted_20210927

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 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.
Project Name Concord Electrical Operations Center T�
2. Location of land -disturbing activity: County Cabarrus
City or Township Concord
Highway/Street 505 Alfred Brown Jr. Latitude 35,22.4733 Longitude 80.34.0549
Court, SW
3. Approximate date land -disturbing activity will commence: 9/10/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.84 acres
6. Amount of fee enclosed: $ 910.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Scott Chunn E-mail Address [e-mail]
Telephone [phone] Cell #
Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
City of Concord 704-920-5304 704-920-6948
Name Telephone Fax Number
635 Alfred Brown Jr. Ct.
Current Mailing Address
Concord NC 28025
City
635 Alfred Brown Jr. Ct.
Current Street Address
Concord NC
State Zip City
State
28025
Zip
10. Deed Book No. 13734 Page No. 318 Provide a copy of the most current deed.
Part B.
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.
Scott Chunn, Deputy Director of Electric Systems [e-mail]
Name E-mail Address
635 Alfred Brown Jr. Ct.
Current Mailing Address
Concord NC 28025
City State Zip
635 Alfred Brown Jr. Ct.
Current Street Address
Concord NC 28025
City
State
Zip

Telephone [phone]
Fax Number 704-920-6948
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:
NIA
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:
NIA
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
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.
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Type or print name Title or Authority
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Signature Date
I, 'Va L V6LP:rcFcL,_7 a Notary Public of the County of CA 9p12-2l/t S
State of North Carolina, hereby certify that o TT C QkA 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 J_d day of J LI Lt
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