NCC221396_FRO Submitted_20220408

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
07.06 EROSION CONTROL FORMS AND CHECKLISTS
07.06.01 EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
No person may initiate any land -disturbing activity as defined in Chapter 158 of the Monroe City Code prior to
completion of this form, and an applicable and acceptable erosion and sedimentation control plan has been approved by
the City of Monroe Engineering Department. (Please type or print)
Part I
1. Name of Project camp Sutton nursery
2. Address where land disturbing activity will take place
3.
4.
5.
6.
7
8.
1800 E. Roosevelt Blvd
Approximate date disturbing activity will commence 1 / 1 / 2022
Purpose of development (residential, commercial, industrial, etc.) Commercial
Total acreage of land to be disturbed or uncovered 7.84
Amount of fee enclosed (fee will be the amount of current policies per acre multiplied by the total number
of acres or any part of an acre from number 5. i.e. 7.28 acres equals 8 acres.) $ 1 300
=$500 + 100(8)
Agent to contact should sediment control issues arise during land disturbing activity
Name Tom Crouch Phone [phone]
Landowner(s) of Record (use blank page to list additional owners)
Name UC QOZB I LLC Name
Mailing Address 231 Post Office Road Mailing Address
Indian Trail, NC 28079
Street Address Street Address
Phone [phone] Phone
Fax Fax
9. Indicate Book and Page where deed of the property where land disturbing activity will take place is recorded
(use blank page to list additional owners)
Book 8147 Book
Page 173 Page
10. Tax Map Parcel Number where land disturbing activity will take place 09155001 B
07-18 Permits, Checklists, and Forms
Division 07

CITY OF MONROE STANDARD SPECIFICATIONS AND DETAIL MANUAL
Part It
1. Person(s) or firm(s) who are financially responsible for this land disturbing activity (use blank page to list
additional owners)
Name UC QOZB II LLC Name
Mailing Address 231 Post Office Road Mailing Address
Indian Trail, NC 28079
Street Address Street Address
Phone [phone] Ph
A) If the Financially Responsible Party is not a resident of North Carolina, give name and address ofa North
Carolina Agent
Name of Registered Agent
Mailing
Street address
Phone Emai
City State zip
Fax
B) 1 f 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 the name and street address of the Registered Agent:
Name of Registered Age
Mailing Address
Street address City State Zip
Phone Email Fax
The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath. I agree to provide corrected information should there be any change in the information provided
herein. (This fot•tn 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 authority to execute instruments
for the financially responsible person)
Dl nis W. Moser
Type or Print Name,-, Title Member Manager
Signatit
Date I ! 1 179Z
a Notary Publliic ol'the County of I Alt Sate of Norlh Caro Iiva,
hereby ccrtil'y that erSY1_I.SJrti� v C�1/ appeared personally bciIbrc r e this day and being chl y sworn acknowk:d ged
t€tat the above form was executed by him. 1
Witness my hand and notarial seal, thisp2 day of_ t� � Ne mbe,-rl -ZAP Z f
SI AL kiAlANALITTLE `
NOTARY
PUBLIC Ul3l.[C (,mil-�
Stanly County (Notary)
North Carolina = l6, � z
My Commission Expires April 16, 2022 My conu�nission expires L
07-I9 Permits, Checklists, and Forms
Division 07