NCC230657_FRO Submitted_20230317

Check if this project is ARPA-funded ❑
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. including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 N/A in the blank.)
Part A.
1. Project Name Water Oak Storm Drainage Improvement Project
2.
3.
4.
5.
"If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street Water Oak Road Latitude de�imai degrees, 35.1795-80.7888
LOngltUde(decimaldegrees)
Approximate date land -disturbing activity will commence: 04/03/2023
Purpose of development (residential, commercial. industrial. institutional. etc.): Municipal Drainage
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.1 0
6. Amount of fee enclosed: S 500 . The application fee of S100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is S900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David EStochen E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
N/A
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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 landovwer(s)is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Company Name
600East 4th Street
Current Mailing Address
Charlotte NC 28202
City State Zip
7U��-����-����
Phone: D�o # ' �` �=� �=�"
KX'ke.F\av'[e-mail]
E-mail Address
600 East 4th Street
Current Street Address
Charlotte NC 28202
City State Zip
Nob* 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 hoconduct 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: Offioe#
NYobi|e#
Name ofIndividual toContact (if Registered Agent iuocompany)
(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:
Nome ufRegistered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Offioe#
Mobile #
Name ofIndividual hnContact (if Registered Agent isacompany)

(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 under 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.
Mike Davis, PE
Type or print name
Director of Storm Water Services
Title or Authority
=;V 20 23
Signature Date'
n 1 -
a Notary Public of the County of
J
State of North Carolina, hereby certify that H 14 Da�� i�- appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal,
GLEY
,- p,R Y ,
s
this :W day ofMat20 �.
, �La
ry
My commission expires it ����

Continued from Items Q & YO in Part of the Financial ResponsibilitylOwnership Form for multiple
VVN?eDs. Attach copies of this page as needed to list all landowners,
Landowner 2 of Record:
Nome Phone: Office# MobUe#�������
Current Mailing Address Current Street Address
City State 2]p City State Zip
Deed Book No. Page No. Provide ocopy ofthe most current deed.
Landowner 3ofRecord:
Name Phone: Office#
MailingCurrent
Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 4ofRecord:
State Zip
Provide a copy of the most current deed.
Name Phone: Office# Mobile #
Current Mailing Address
City State
Deed Book No.
__________
Landowner 5ofRecord:
Name
Current Mailing Address
City State
Deed Book No.
Current Street Address
Zip City State Zip
Page No. Provide acopy ofthe most current deed.
Phone Office#
Current Street Address
Zip City
Page No.
State Zip

Company 2Name
Current Mailing Address
City State
Phone: 0ffioe#
E-mail Address
Current Street Address
Zip city State
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Phone: Offimy#
'
Zip City State
Mobile #
Company 4Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Phone: Offioe#
Zip Cby State
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
us
ME
City State Zip City State Zip
Phone: Office# Mobile #