NCC223678_FRO Submitted_20221031

FINANCIAL 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name RICHFIELD CLIMATE CONTROL EXPANSION
2,
I
4.
5.
Location of land -disturbing activity: CountySTANLY City or Township RICHFIELD
CHURCH ST 35.45250000 80.24805656
HlghwaylStreet Latltude(decimal degrees) Longitude(dedmal degrees)__
Approximate date land -disturbing activity will commence: 9.15.22
Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.83
6. Amount of fee enclosed: $ 300 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Email Address
Joshua Davis [e-mail]
_
Phone: office # 980-785-3882 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
505 E. Church St., LLC 980-785-3882
Name
PO Box 221633
Current Mailing Address
Charlotte, NC 28222
City State Zip
10. Deed Book No. 171 1 Page N
Phone: Office ##
720-800-2142
Mobile #
700 E. Morehead St., Suite 100B
Current Street Address
Charlotte, NC 28202
City
221
State
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
505 E. Church St., LLC
Company Name
PO Sox 221633
Current Mailing Address
Charlotte, NC 28222
City State Zip
Phone: office # 980-785-3882
[e-mail]
E-mail Address
700 E. Morehead St. Suite 100E
Current Street Address
Charlotte, NC 28202
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2: (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: office # Mobile f#
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
®avid Brent Wright Jr.
Name of Registered Agent
PO Box 221633
Current Mailing Address
Charlotte, NC 28222
City
State Zip
[e-mail]
E-mail Address
700 E. Morehead St., Suite 100B
Current Street Address
Charlotte, NC 28202
City State Zip
Phone: office # 980-785-3882 Mobile # [phone]
Brent Wright
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me Lander oath. (This form must be signed by the Financially Responsible Person if an individual(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Joshua Davis
Type or print name
Signature _
Managing Member
Title or Authority
8/ 15122
Date
L-_ r- a Notary Public of the County of j)ev)k� Ol.e 0114
Of
State of-i � ii 4a hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/hew
Witness my hand and notarial seal, this 15-day of C.eo 20 a.9
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N-V MOOI
otary
NOTARY PUBLIC My commission expires
Commonwealth of Virginia
Req. �61933907
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