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HomeMy WebLinkAboutNCC221999_FRO Submitted_20220527FINANCIAL 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. North End Around Taxiway Package 1 1 . Project Name 2 3 4 Location of land -disturbing activity: County Mecklenburg city or Township Charlotte Highway/Street Airport Overlook Dr. Latitude 35.230669 - Longitude 80.956833 Approximate date land -disturbing activity will commence: May 12, 2022 Purpose of development (residential, commercial, industrial, institutional, etc.) Industrial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 233 6. Amount of fee enclosed. S 15,145.00 — 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� Nam, Eric Rysdon E-mail Address eric.rysdon@hdrinc.com Telephone 980-337-5021 Cell # 704-808-371 Fax # E0 Landowner(s) of Record (attach accompanied page to list additional owners)� City of Charlotte Name Telephone Fax Number 600 E. 4th Street 5501 Josh Birmingham PKWY Current Mailing Address Charlotte, NC 28202 City 10. Deed Book No.03089 State Current Street Address Charlotte, NC 28202 Zip City State A r, r, Z-1p 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. City of Charlotte - Charlotte Douglas International Airport Jeffrey. McSwain@cltairport.com Name E-mail Address P.O. Box 19066 5601 Wilkinson Blvd Current Mailing Address Charlotte NC 28208 City State Zip Telephone 7046221303 Current Street Address Charlotte NC 28208 City State Zip 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 Current Mailing Address E-mail 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 Current Mailing Address City State Zip Telephone E-mail Address Current Street Address C ity Fax Number State Zip 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. _je'-w Type or pri t name Title or A6thority S'�Rfa to Date - --------- - ---------------------- - --------- --------------- - ------------ - - --- - -- - 04 a Notary Public of the County of I State of North Carolina, hereby certify that C1641 appeared personally before me this day and being dul� i4orn acknowledged that the above form was executed by him. Witness my hand and notarial seal, owl I Ii"i" G. NOTARY PUBLIC 0 Ili URG //110 I it 10" this day of 20 Notary My commission expires ZL- �, --,,?- ed,; 3 —