NCC223143_FRO Submitted_20220922

FINANCIAL 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 N/A in the blank.)
Part A. Carolinas Aviation Museum - Sitework
1. Project Name
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street Minuteman Way Latitude 35*13'32"IV Longitude 80*56' W
3. Approximate date land -disturbing activity will commence: February 2022
A. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.3 Acres
6. Amount of fee enclosed: $ 344.50 . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Leslie Jo Hurwitz E-mail Address [e-mail]
Telephone 704.564.791 7 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Charlotte - Aviation
Name Telephone
600 E. Fourth Street
Current Mailing Address
Charlotte, NC 28202
City State
10. Deed Book No. None Found
Current Street Address
Zip City
Page No.
State
Fax Number
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 - Aviation [e-mail]
Name
5601 Wilkinson Blvd
Current Mailing Address
Charlotte, NC 28208
City
Telephone
E-mail Address
5601 Wilkinson Blvd
Current Street Address
Charlotte, NC 28208
State Zip 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
Teleph
E-mail Address
Current Street Address
Zip City State Zip
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 information should there be any change in the information provided herein.
Jack Christine
or print nAn]e
re
Chief Operating Officer
Title or Authority
�,1 A —
Date'
a Notary Public of the County of�F'�Q. JC2C'/
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State of North Carolina, hereby certify that appeared
personally before me this day and being d ly sworn acknowledged that the above form was
executed by him.
Witness nr X�Wlhldt*� notarial seal,
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NOTARY
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this day of &4�zz�20
Notary JJ
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