NCC233723_FRO Submitted_20231222

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 NCGO1 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 NameWalker Branch & Hoover Creek Greenway
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
NA
2. Location of land-disturbing activity: CountyMecklenburg City or Township Charlotte
Old Steele Creek Rd 35.100582 -80.981691
Highway/Street Latltude(decimal degrees) Longltude(decimaldegrees)
3. Approximate date land-disturbing activity will commence: 11/1/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Greenway
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10.56 AC
6. Amount of fee enclosed: $1 '1 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 0 Enclosed El No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Jennifer Brooks E-mail Address [e-mail]
Phone: office# 980-314-2428 Mobile# NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mecklenburg County 980-314-2428 NA
Name Phone: Office# Mobile#
600 E 4th St / 11th Floor 600 E 4th St / 11 th Floor
Current Mailing Address Current Street Address
Charlotte, NC 28202 Charlotte, NC 28202
City State Zip City State Zip
10. Deed Book No.29465 Page No.495 Provide a copy of the most current deed.
Landowner also includes: Landowner also includes:
Deed Book No. 21482 Page No. 348 Deed Book No. 29041 Page No. 966
Deed Book No. 21737 Page No. 668 Deed Book No. 28426 Page No. 219
Deed Book No. 24043 Page No. 681 Deed Book No. 20939 Page No. 413
Deed Book No. 29392 Page No. 718

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:
Thomas Lott and Dallas Lott NA NA
Name Phone: Office# Mobile#
14802 Jerpoint Abby Dr 14802 Jerpoint Abby Dr
Current Mailing Address Current Street Address
Charlotte, NC 28273 Charlotte, NC 28273
City State Zip City State Zip
Deed Book No.26421 Page No.338 Provide a copy of the most current deed.
Landowner 3 of Record:
Progress Residential Borrower 9 LLC NA NA
Name Phone: Office# Mobile#
PO Box 4090 14520 Asheton Creek Dr
Current Mailing Address Current Street Address
Scottsdale, AZ 85261 Charlotte, NC 28273
City State Zip City State Zip
Deed Book No.33788 Page No. 322 Provide a copy of the most current deed.
Landowner 4 of Record:
Arc RGCHRNC001 LLC NA NA
Name Phone: Office# Mobile#
23425 Commerce Park Ste 103 13540 Hoover Creek BV
Current Mailing Address Current Street Address
Cleveland, OH 44122 Charlotte, NC 28273
City State Zip City State Zip
Deed Book No.30317 Page No. 500 Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
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 landowner(s)is
an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies).
Mecklenburg County [e-mail]
Company Name E-mail Address
600 E 4th St / 11 th Floor 600 E 4th St / 11 th Floor
Current Mailing Address Current Street Address
Charlotte, NC 28202 Charlotte, NC 28202
City State Zip City State Zip
Phone: Office# 980-314-2428 Mobile#NA
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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.
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.
Jennifer Brooks Project Manager
Type of print name Title or Authority
'/(/ V t/' ✓�/� 6/20/23
Sig6ature I Date
I, .iC{t"-,1 CO , a Notary Public of the County of Acellep
State of North Carolina, hereby certify that �� TO 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, this v✓day of _(�AC. , 20
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