NCC221466_FRO Submitted_20220414

Mecklenburg County Soil. Erosion and
Sedimentation Control Ordinance
A Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. If the
financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where Iand-disturbing activity is to be undertaken:
Pineville Distribution Lot 3
2. Address of land -disturbing activity:
10121 Pineville Distribution St, Pineville, NC 28134
3. Approximate date land -disturbing activity will commence: April 20 2022
Montle
4. Purpose of development (Residential, Commercial, Industrial, etc.): Industrial
5. Approximate acreage of land to be disturbed or uncovered: 3.07 AC
6. Total site acreage: 3.67 AC
Day Year
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Berkshire Partners #26 LLC
Address: 215 Queens Road, Charlotte, NC 28204
Telephone: [phone]
Email Address: [e-mail]
Owner ##2 Name:
Address:
Telephone:
Email Address:
Fax:
Fax:
S. Indicate Book and Page where the deed or instrument is tiled (use blank pages to list
additional deeds or instruments as necessary):
Book 35247
Page 478
Boole Page
Book
Page
Page
Form Revised 12-2016
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Berkshire Partners #26 LLC
Address: 215 Queens Road, Charlotte, NC 28204
Telephone: [phone]
Email Address: [e-mail]
Fax: 176e4 • 3 ? 2 • o � o
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
,1:
Telephone:
Email Address:
Fax:
3. The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath. (This form must be signed by the financially responsible
person if an individual or by an officer, director, partner, . attorney -in -fact, or other person
with authority to execute instruments for the financially responsible company or entity, if not
an individual.)
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a Notary Public of the
County of CabaIruf Cc" n!!!, , State of Na" Carojrl1 a hereby
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before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand arkd notaridseal, this Z nd day of kblru aL14 , 20 Z Z-
Notary Signature: Gf1
My Commission e 'res: NOTARY PUBLIC ®m b��
North Carolina '4
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ommission Expires september 49, 2025
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Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave. a
Charlotte, NC 28208-5237 6�
Phone [phone]