NCC215806_FRO Submitted_20211019

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. Brookdale Village Townhomes
1. Project Name g
2. Location of land -disturbing activity: County Cabarf us City or Township Harrisburg
Highway/Street Plaza Street Ext. Latitude 35.281669 Longitude-80.668732
3. Approximate date land -disturbing activity will commence.-
4
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.75
6. Amount of fee enclosed: $ $65 x 5ac = $325 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 Brad Dyer E-mail Address [e-mail]
Telephone [phone] Cell # 980-721-0919 Fax 4
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MTS CLT, LLC
980-721-0919
Name
Telephone Fax Number
2857 Westport Road
2857 Westport Road
Current Mailing Address
Current Street Address
Charlotte NC
28208 Charlotte NC 28208
City State
Zip City State Zip
10, Deed Book No,13646
Page No. 0315 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.
MTS CLT, LLC
[e-mail]
Name
E-mail Address
2857 Westport Road
2857 Westport Road
Current Mailing Address
Current Street Address
Charlotte NC
28208 Charlotte NC 28208
City State
Zip City State Zip
Telephone [phone]
Fax Number

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:
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:
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.
,r L, 11 -4?
Type pr- rint name Tittle or Authority
Signature Date
I, ii , a Notary Public of the County of
State of North Carolina, hereby certify that _j r Ue r' appeared
personally before me this day and being duly sworn acMowledged that the above form was
executed by him.
Witness my hand and notarial seal, this � ay of a06 1b , 20 2
r
Nd�ary
Seal
DANIELLE C. ANDERSON My commission expires q-30 —4204 2_*1
NOTARY PUBLIC
Mecklenburg County
North Carolina
My Commission Expires July 30, 2023