NCC240080_FRO Submitted_20240112

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. Project Name Earnhardt Town Center
2. Location of land-disturbing activity: County Cabarrus City or Township Kannapolis
Highway/Street Dale Earnhardt Blvd Latitude(aeGmai degrees)35.47123 Longitudeiae�imai degrees)-80.59714
3. Approximate date land-disturbing activity will commence: 1 1/1/2023
4. Purpose of development(residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):28•00
6. Amount of fee enclosed: $2,800.00 . 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 El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Daryl Michael Hayes E-mail Address [e-mail]
Phone: Office# 704-804-4061 Mobile#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
CP Kannapolis Investments, LLC 704-804-4061
Name Phone: Office# Mobile#
101 N Tryon St, Suite 112 101 N Tryon St, Suite 112
Current Mailing Address Current Street Address
Charlotte NC 28246 Charlotte NC 28246
City State Zip City State Zip
10. Deed Book No. 16119 Page No. 102 Provide a copy of the most current deed.
108, 113, 117, 122, 126, 129,
133, 137, 143

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)may be listed as the financially responsible party(ies).
CP Kannapolis Investments, LLC [e-mail]
Company Name eDrD E-mail Address
101 N. Tryon Street, Suite ,. 101 N. Tryon Street, Suite r CO
Current Mailing Address i12 -(p Current Street Address
Charlotte, NC s', v st zi Charlotte, NC awirmrz
City State Zip City State Zip
Phone: Office# 704-804-4061 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:
Name ofiRegistered Agent / E-mail Add ss
Current Mailij Address Current Street Address
\61te- Ba'4-Co 1 eMC- - 2-4-6
City State Zip City State Zip
Phone: Office# 10--?Ozt-----4-tio t Mobile# —101—1�'r 7\C f
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Name oftni,ividual 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:
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Name f 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.
Daryl Michael Hayes Managing Member
_Type or print name Title or Authority
Vcq
Sig ature Date
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01-:Ak---c , a Notary Public of the County of clic c 16-e4
State of North Carolina,hereby certify that 0 4 IyL fli,`c>1.4-E(.. hi 4-y Ls appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
q'fji
Witness my hand and notarial seal, this day of , 20 3
pg.t. (44L- 4Dc[i
et, ary
Seat tr.
NOTARY PUBLIC My commission expires'57 29 77) e
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