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HomeMy WebLinkAboutNCC231310_FRO Submitted_20230505 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 and/ or fax information unavailable, place N/A in the blank.) P1.art AProject Name Harris Teeter Fuel #129 - Sun Valley 2. Location of land-disturbing activity: County Union City or Township Indian Trail Highway/Street Old Monroe Rd Latitude 35.049037 Longitude-80.648832 3. Approximate date land-disturbing activity will commence:October 2021 4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.74 6. Amount of fee enclosed: $260 . The application fee of$65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585). 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 Kevin Lentz E-mail Address klentz@harristeeter.com Telephone 704-754-3643 Cell # Fax# 9. Landowner(s) of Record (attach accompanied page to list additional owners): Mustang Park, LLC Name Telephone Fax Number 1012 Shippon Lane 1012 Shippon Lane Current Mailing Address Current Street Address Waxhaw, NC 28173 Waxhaw, NC 28173 City State Zip City State Zip 10. Deed Book No. 07773 Page No.011 O 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. Harris Teeter Properties, LLC Jphares@harristeeter.com Name E-mail Address 701 Crestdale Road 701 Crestdale Road Current Mailing Address Current Street Address Matthew, NC 28105 Matthew, NC 28105 City State Zip City State Zip Telephone 704-844-3100 Fax Number 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: Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone Fax Number (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: Jacob Phares Jphares@harristeeter.com Name of Registered Agent E-mail Address 701 Crestdale Road 701 Crestdale Road Current Mailing Address Current Street Address Matthews, NC 28105 Matthews, NC 28105 City State Zip City State Zip Telephone 704-844-3100 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 change in the information provided herein. Jacob Phare 7Vice President Type or pri' - Title or Authority ,:iig-,W/ S Date rY11 l ,1 S�1 1 (lit 5 , a Notary Public of the County of MeG kle,I')hU rig State of North Carolina, hereby certify that 0aCO b P h a re,s appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this o2 Li- day of NAgU , S� 20 a-- I \\\\t i i i i r l/,,/ J `FJ/� ► /�� o Ahid.j.) �0 T AR y Notary 6 Sea l ' / 1 (1 �O2( �c�7+ Ug t_IG �; My commission expires O URG CdJ��`�