NCC240549_FRO Submitted_20240227

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL,ACT
No person may initiate any land-disturbing activity on one or more acres a 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. Part .roject Name Zion Church rd. (SR 1155) 12" Waterline Project No. 2020-077
2. Location of land-disturbing activity: County Cabarrus City or Township Concord
Highway/Street Zion Church Rd. Latitude 35.3729 Longitude-80.5800
3. Approximate date land-disturbing activity will commence:03/1 1/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Public Utility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.50
6. Amount of fee enclosed: $ n/a . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Alex Deal E-mail Address [e-mail]
Telephone [phone] Cell# 704-699-5667 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Concord 704-920-5555
Name Telephone Fax Number
PO Box 308 35 Cabarrus Ave. W
Current Mailing Address Current Street Address
Concord NC 28026-0308 Concord NC 28025
City State Zip City State Zip
10. Deed Book No. Page No. Provide'la 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.
Carolina Siteworks Inc. [e-mail]
Name E-mail Address
P.O Box 280 300 Wade Dr.
Current Mailing Address Current Street Address
China Grove NC 28023 China Grove NC 28023
City State Zip City State Zip
Telephone [phone] 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 perso engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Nam . If the Financially Responsible
Party is a Corporation, give name and street address of the Registered gent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Addre s
City State Zip City State Zip
Telephone 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.
Alex Pc4 / Pr elect Al et PIaycr
Type
or print name Title or Authority
,6 G 2 - 2 6-2`(
Signature Date
Christina Miller , a Notary Public of the County of
State of North Carolina, hereby certify that Alex Deal appeared
personally before me this day and being duly sworn acknowled ed that the above form was
executed by him. n
Witness my hand and notarial seal, this 2 day of Pe--lb , 20Z 7
F• ��% Notary
Seal = -NARY cf. `� 7 a�a�
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