NCC215595_FRO Submitted_20211011

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. DairyBranch Tributary Sed efield Segment
1. Project Name y — g g
2.
3
0
Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street Cumberland Ave. Latitude 35.192729 Longitude-80.844802
Approximate date land -disturbing activity will commence: Summer,-Z ®,-7 I
Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.00
6. Amount of fee enclosed: $ 390.00 , 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 Jeffrey McClanahan E-mail Address [e-mail]
Telephone [phone]
Cell # 704-995-7489
Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached
Name
Current Mailing Address
City State
10. Deed Book No. See Attached
Telephone
Current Street Address
Zip City
Fax Number
State Zip
Page No. Provide a copy of the most current deed.
Part B.
1. 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.
Charlotte Water
Name E-mail Address
5100 Brookshire Blvd 5100 Brookshire Blvd
Current Mailing Address
Charlotte, NC 28216
City State
Telephone [phone]
Current Street Address
Charlotte, NC 28216
Zip City
Fax Number
State
Zip

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:
N/A
N/A
Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip City State Zip
N/A
N/A
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:
N/A
N/A
Name of Registered Agent
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip City State Zip
Telephone N/A Fax Number N/A
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.
JosAph C. Wilson
Typ r pri t name
Si re
Chief Engineer
Title or Authority
6?6V/'1Z11
Date
I, Erg y) Le- CeffV-Ca Notary Public of the County of
State of North Carolina, hereby certify that "A C �djw/w-4 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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