NCC224064_FRO Submitted_20221213

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. Buffalo Terrace Apartments
1. Project Name p
2. Location of land -disturbing activity: County Cabarrus City or Township Concrod
Highway/Street Concord Parkway North Latitude 35.403340 Longitude-80.610392
3. Approximate date land -disturbing activity will commence:A.S.A.P.
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.61 Acres
6. Amount of fee enclosed: $2,205.0 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Matt Raab E-mail Address [e-mail]
Telephone [phone] cell # 336-880-3300 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Buffalo Terrace, LP N/A [phone]
Name Telephone Fax Number
1329 E. Lark Street 1329 E. Lark Street
Current Mailing Address Current Street Address
Springfield, MO 65804 Springfield, MO 65804
City State Zip City State Zip
10. Deed Book No. 13724 Page No. 12 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.
Buffalo Terrace, LP N/A
Name
1329 E. Lark Street
Current Mailing Address
Springfield, MO 65804
City
State Zip
E-mail Address
1329 E. Lark Street
Current Street Address
Springfield, MO 65804
City State Zip
Telephone [phone] Fax Number N/A

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:
Corporation Service Company N/A
Name
2926 Glenwood Ave Ste 550
Current Mailing Address
E-mail Address
2926 Glenwood Ave Ste 550
Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State zip
Telephone
N/A
Fax Number N/A
(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:
Corporation Service Company
N/A
Name of Registered Agent
F-mail Address
2926 Glenwood Ave Ste 550
2926 Glenwood Ave Ste 550
Current Mailing Address
Current Street Address
Raleigh, NC 27608
Raleigh, NC 27608
City State ,Zip
City State Zip
Telephone N/A
Fax Number N/A
(c) In order to facilitate Express Permitting, it
is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Borum, Wade, & Associates
[e-mail]
Engineering Firm or other consultant
E-mail Address
Steve Schlegelmilch
(336) 275 - 0471 ext. 116 (336) 275 - 3719
Individual contact person (type or print)
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 information should there be
any b� gelation provided herein.
Signatu
O ZUV1V'
Title or Authority
Date
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VI, t/ C a a Notary Public of the County of t� Ll (Ul
State of North Carolina, hereby certify that V attoi`/Eo /-aiA- tf.irllwuA appeared personally
before me this day and being duly sworn acknowlgdgdd that the above ffopr�m� was executed by him.
Witness my hand and notarial seal, this TZ ",day of 20
OVA lk
No ary
Seal r� /] A
y,p" K. NEWBERRY My commission expires t�Y { `f U r
My Commission Expires
NQr�tr; Jan. 20, 2020
rssEu Christian County
°i`t Commission # 13542358