NCC223191_FRO Submitted_20220912

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM DJE"''
SEDIMENTATION POLLUTION CONTROL ACT /0'a and q� ai��E,�<<,;
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No person may initiate any land -disturbing activity on one or more acres as covered by the Act before tf�',
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 TaxiwayOld Dowd Road Relocation
1. Project Name
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street Old Dowd Road Latitude 35.2349 Longitude-80.9636
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public Roadway
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 58.0
6. Amount of fee enclosed: $ 3770 . 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 Cody Smith E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Charlotte [phone]
Name
Telephone Fax Number
600 East Fourth Street
Same
Current Mailing Address
Current Street Address
Charlotte, NC 28202
Same
City State Zip
City State Zip
10. Deed Book No. Page No.
Provide a copy of the most current deed.
Note: See attached sheet for property owner list
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.
CDIA /,�j�-��`���
[e-mail]
Name
E-mail Address
5601 Wilkinson Blvd
Same
Current Mailing Address
Current Street Address
Charlotte, NC 28208
Same
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 ir}f mation should there be any change in the information provided herein.
Type or pri t ame Title or Authority
6 05 Z9Z/
Si atu Date
a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being ul worn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of , 20
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NOTARY = Notary
° Seal
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My commission expires 11117URG CO
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