NCC230921_FRO Submitted_20230403

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 N/A in the blank.)
Part A.
1
2
Project Name Stowe Regional WRRF Access Roads
Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Belmeade Dr 35°17'18.53"N 80°59'3C27"W
Highway/Street LatltUde(decimal degrees) LongltUde�decima� degrees)
3. Approximate date land -disturbing activity will commence: February 23, 2023
4
Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.1
6. Amount of fee enclosed: $ 1700 . 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 Nicole Bartlett E-mail Address Nicole. [e-mail]
Phone: Office # 704-336-1007 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Charlotte
Name
600 E 4th St
Current Mailing Address
Charlotte, NC 28202
City State
10. Deed Book No. 28400
Phone: Office # Mobile #
600 E 4th St
Current Street Address
Charlotte, NC 28202
Zip City State Zip
Page No. 380, 386 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 orif 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
Nicole. [e-mail]
E-mail Address
5100 Brookshire Blvd
Current Street Address
Charlotte, NC 28216
City State Zip City State Zip
Phone: Office # 704-336-1007 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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City
Phone: Office # N/A
N/A
State
N/A
E-mail Address
_ N/A
Current Street Address
_ N/A
Zip City State Zip
Mobile # N/A
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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City
Phone: Office # N/A
N/A
State Zip
'►lam
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 Chief Engineer for Charlotte Water
TXp,6 or print name
Silar attire
Title or Authority
,25&& �
Date
v � oI, g 4 a Notary Public of County of
State of North Carolina, hereby certify that W+ I S"'� appeared perso Ily
before me this day and being duly sworn acknowle ged that
the above form was executed by him/her.
Witness my hand and notarial seal, this day of 20
4NA S%4p
Notary
O 'n—
n`' ocl 2a My commission expires U o202�
I "A
V
..s'�A

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Catawba Lands Conservancy 704-342-3330
Name
4530 Park Rd. Ste 420
Current Mailing Address
Charlotte, NC 28209
Phone: Office # Mobile #
4530 Park Rd. Ste 420
Current Street Address
Charlotte, NC 28209
City State Zip City
Deed Book No. 26977 Page No. 599
Landowner 3 of Record:
N/A
Name
N/A
Current Mailing Address
N/A
City State
Deed Book No. N/A
Landowner 4 of Record:
N/A
State Zip
Provide a copy of the most current deed.
Phone: Office #
N/A
Current Street Address
N/A
Zip City
Page No. N/A
N/A
Mobile #
State Zip
Provide a copy of the most current deed.
N/A
N/A N/A
Name
Phone: Office # Mobile #
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip
City State Zip
N/A
N/A
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
N/A
N/A N/A
Name
Phone: Office # Mobile #
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip
City State Zip
N/A
N/A
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A N/A
Company 2 Name E-mail Address
N/A N/A
Current Mailing Address
N/A
City State
Phone: Office # N/A
N/A
Company 3 Name
N/A
Current Mailing Address
N/A
City State
Phone: Office # N/A
N/A
Current Street Address
N/A
Zip City State
Mobile # N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip City
Mobile # N/A
N/A
State
Zip
Zip
Company 4 Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip City State Zip
Phone: Office # N/A
Mobile # N/A
N/A
N/A
Company 5 Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State
Zip City State Zip
Phone: Office # N/A
Mobile # N/A