NCC232196_FRO Submitted_20230724

Financial Responsibility/Ownership Form Sedimentation Pollution Control Ordinance
No person may initiate any land-disturbing activity on one or more acres as covered by the ordinance before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Rowan County
Environmental Management Department.
Part A Parcel ID Number
yoO0
1.Project Name*
St r\
2.Location of land-disturbing activity(Highway/Street)*
110,1(ISO A SGt-liS bu ry , /kJ(—
Latitude Longitude
35: (0NI(05 - 60, 5. 6Ga
3.Approximate date land-disturbing activity will be commenced
17/24/2023
4.Purpose of development(residential,commercial,industrial,etc.)
Ee, \61.sin,,\--\(A, t
5.Approximate acreage of land to be disturbed or uncovered*
4(0
6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity*
e—cofq 00—(1 0,-Koo
*this information will be made available on the Rowan County Planning 8 Development website.
Email Address
&O1rO (Ie ve_ r\., c6 (v)

7.Landowner of Record Landowner of Record
0.2 4O(-\-U � , KC,
Name Name
Current Mailing Address Current Mailing Address
6o4-c Prrrot�%cLuL tdu ekr,r ciMk
.jL --ce4---73
8.Recorded in Deed Book Number Page Number
Part B
1.Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this land-
land-disturbing activity disturbing activity
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
8(3 2S E 1(6 011 j CLU2- 1 L ct t C c LC3
a-i3
Phone Number Phone Number
(o3-O- 3-7 3
a.If the Financially Responsible Party is not a resident of North Carolina,give name and street address of a North Carolina
Agent.
Name of Agent Name of Agent
Current Mailing Address Current Mailing Address
Phone Number Phone Number

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 the name and street
address of the Registered Agent.
Name of Registered Agent
C ( Lupo cR:h ov\
Current Mailing Address Current Street Address
I GO VA-e_ CU'Q- a. ;.;L_ 1(4) M-€ C 4-- 1
1-dam€ h
Ca 0 I t (0 u t
Telephone Number Telephone Number
9)-C - 7(39 g1q -1t3J
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 authority to execute instruments for the Financially Responsible Person).
I agree to provide correctional information should there be any change in the information provided herein.
Name Title or Authority
eor5 t 84/4 lLI fr) i a l 'wt.,Al P,0e5 M.-t4S-r,-
Signature Date
7/17/2023
I, C' e a Notary Public of the County of /A{,(/ 'GA6A State of North Carolina,
hereb,/certify that , IC CO+fN1peared personally before me this(day annbeing dul sw rn acknowledged
that the above form was ete 4�F ecuted by hiin/her.Witness my hand and seal of Notary,this 19 day of J t�.k.7 ,2023
Notary My commission expires
13/3/2027
Seal •
LOGAN F. CREECH
Notary Public. North Carolina
Checklist Mecklenburg County
Download a copy of the Erosion and Sedimentation My Commission Expires
Control Plan Checklist(PDF) March 03,2027_