NCC250191_FRO Submitted_20250122

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.)
Part A.
1. Project Name MECKLENBURG COUNTY FACILITY BASED CRISIS CENTER
2. Location of land-disturbing activity: County MECKLENBURG City or Township CHARLOTTE
Highway/Street RENO AVENUE Latitude 35.2559 Longitude -80.8696
3. Approximate date land-disturbing activity will commence: OCTOBER 7. 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.90
6. Amount of fee enclosed: $ 300 . 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).
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 STEVEN WALLACE E-mail Address Steven•Wa/lace@YlecklenburgCountyNC•gov
Telephone (704) 565E-5563 Cell# N/A Fax# N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
/YJECKLENBURG COUNTY 56�F-5563 N/A
c/o Real Estate / Finance Dept (705�)
Name Telephone Fax Number
600 E. 4th STREET 77th FLOOR [Same]
Current Mailing Address Current Street Address
CHARLOTTE NC 28202 [Same]
City State Zip City State Zip
10. Deed Book No. 05287 Page No. 705 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.
MECKLENBURG COUNTY Steven•Wallace@/VlecklenburgCountyNC•gov
Name E-mail Address
600 E. 4th STREET, 77th FLOOR [Same]
Current Mailing Address Current Street Address
CHARLOTTE NC 2E202 [Same]
City State Zip City State Zip

Telephone (70g) 56g-5563 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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
Steven Wallace Steven•Wallace@MecklenburgCountyNC•gov
Name of Registered Agent E-mail Address
600 E. 'fth STREET, 77th FLOOR [Same]
Current Mailing Address Current Street Address
CNARGOTTE NC 25202 [Same]
City State Zip City State Zip
Telephone (70g) 56gf-5563 Fax Number N/A
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.
STEVEN WALGACE
(Mecklenburg County AFM) PROJECT MANAGER
Type or print n. e Title or Authority
Signat Date
, a Notary Public of the County of
State of North Carolina, hereby certify that 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 I n day of 20024
Ale
of ry
Seal A,'ar /)
My commission expires (Y ") oC,(p �(