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HomeMy WebLinkAboutNCC240839_FRO Submitted_20240327 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 Name Kannapolis Highway 73 7-eleven *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). N/A Ca b a r r u s Kannapolis City limits,Concord Address 2. Location of land-disturbing activity: County City or Township NC Hwy. 73 35.436136 -80.688194 Highway/Street Latltude(decimal degrees) Longltude(decimai degrees) 3. Approximate date land-disturbing activity will commence: 1/1/24 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.92 6. Amount of fee enclosed: $700 . 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 1:1 Enclosed 0 No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Jamie Diller E-mail Address jdillen@csere.com Phone: Office# (704) 414-7472 Mobile# (704) 517-4650 9. Landowner(s) of Record (attach accompanied page to list additional owners): Highway 73 Parkway LLC 7042482100 Name Phone: Office# Mobile# 2400 South Boulevard, Suite 300 2400 South Boulevard, Suite 300 Current Mailing Address Current Street Address Charlotte NC 28203 Charlotte NC 28203 City State Zip City State Zip 10. Deed Book No.00094 Page No. 00052 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) may be listed as the financially responsible party(ies). C4-AR 7-Eleven, LLC jdillen@csere.com Company Name E-mail Address 801 East Blvd. 801 East Blvd. Current Mailing Address Current Street Address Charlotte NC 28203 Charlotte NC 28203 City State Zip City State Zip Phone: Office# (704) 414-7472 Mobile# (704) 517-4650 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: Barry James bjames@csere.com Name of Registered Agent E-mail Address 801 East Blvd. 801 East Blvd. Current Mailing Address Current Street Address Charlotte NC 28203 Charlotte NC 28203 City State Zip City State Zip Phone: office# (704) 414-7477 Mobile# (704) 414-7477 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 N/A Name of Registered Agent 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 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. Barry James Authorized Signatory Type or print name Title or Authority 2/20/24 Signat Date James R. Dillen , a Notary Public of the County of Mecklenburg State of North Carolina, hereby certify that Barry James 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 20th day of February 20 24 / t D.b Nota Seal 6/30/26 My commission expires JAMES R. DtLLEN NOTARY PUBLIC tl Mecklenburg County, North Carolina