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HomeMy WebLinkAboutNCC230586_FRO Submitted_20230324FINANCIAL 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 address or phone number is unavailable, place NIA in the blank.) Part A. I, Project Name Clarke Creek Pump Station 2. Location of land -disturbing activity: County Mecklenburg City or Township Huntersville 15744 Huntersville Concord Rd 35.4'143-80.7857 Highway/Street Latltude(de.imaidegrees) longitude(decimatdegrees) 3. Approximate date land -disturbing activity will commence: October 28th, 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal (Utility) 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.50 6. Amount of fee enclosed: $ 1000.00 . 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 0 No 0 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Chuck Bliss E-mailAddresschuck.bliss@charlottenc.gov Phone: Office # 704-995-7518 Mobile # n/a 9. Landowner(s) of Record (attach accompanied page to list additional owners): Metrolina Greenhouses Inc. 7048751371 nla Name Phone: Office # Mobile # 16400 Huntersville Concord Rd nla Current Mailing Address Current Street Address Huntersville NC 28078 nla City State Zip City State Zip 10. Deed Book No. 34068 Page No. 976 Provide a copy of the most current deed. Part S. 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). City of Charlotte Company Name 5100 Brookshire Blvd Current Mailing Address Charlotte NC 28216 City State Zip Phone: Office # chuck.hliss@charlottenc.gov E-mail Address n/a Current Street Address n/a City State Zip Mobile # 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: n/a Name of Registered Agent n/a Current Mailing Address n/a City State n/a E-mail Address n/a Current Street Address n/a Zip City Phone: office # n/a Mobile # n/a n/a Name of Individual to Contact (if Registered Agent is a company) State Zip (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: n/a Name of Registered Agent n/a Current Mailing Address n/a City State Zip Phone: Office # n/a n/a n/a E-mail Address n/a Current Street Address n/a City State Zip Mobile # n/a 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. n/a 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. Joseph C. Wilson Type,q(print name S Chief Engineer Title or Authority Date [ Locb q.-- Lt v\Aea Notary Public of the County of I\A'C1� State of North Carolina, hereby certify that JO Se to i appeared personally before me this day and being duly sworn acknowled ed that the above form was executed by him/her. Witness my hand and notarial seal, this 1 day of Se 20 'Z Z Notary Seal My commission expires 1 a l as l.ATOYA LINDESAY Notary Public - North Carolina Mecklenburg County My Commission Expires Dec 1, 2025