HomeMy WebLinkAboutNCC220748_FRO Submitted_20220302FINANCIAL 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. Belk Tonawanda Park Phase 1 B
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Monroe
Highway/Street N Charlotte Ave Latitude 34.9869Longitude-89.5525
3. Approximate date land -disturbing activity will commence: 12/03/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Civic
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3•00 ac
6. Amount of fee enclosed: $ 195•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 Ryan Jones - Parks & Recreation Director E-mail Address rjones@monroenc.org
Telephone 704-282-4659 Cell # Fax #
9
10
Landowner(s) of Record (attach accompanied page to list additional owners):
City of Monroe (704) 282-4659
Name Telephone
PO Box 69
Current Mailing Address
Monroe NC 28111
Current Street Address
City State Zip City
Deed Book No. 7069 and 5517 Page No.19 and 667
State
Fax Number
914
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 flan is a sole proprletorshr'p,
the name of the owner or manager may be listed as the financially responsible party.
City of Monroe rjones@monroene.org
Name
2325 Hanover Drive
Current Mailing Address
Monroe, NC 28110
City State
Telephone 70 4-282-4659
E-mail Address
Current Street Address
Zip City State
Fax Number
go
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
correcte formation should there be any change in the information provided herein.
B ' kne Interim City Manager
yp or Title or Authority
02/03/2022
Sign re Date
Bridgette H. Robinson , a Notary Public of the County of Union
State of North Carolina, hereby certify that Brian J. Borne 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 3rd day of February
Seal
. 20 22
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My commission expires 01 /13/2023