NCC223138_FRO Submitted_20220906

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
1. Project Name
Speedway Business Park Lot 7
2. Location of land -disturbing activity (Highway/Street)
1235 Speedway Blvd.
Parcel ID Number
401A025
Latitude Longitude
35.62 80.5
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3. Approximate date land -disturbing activity will be commenced
8/15/2022
4. Purpose of development (residential, commercial, industrial, etc.)
commercial
5. Approximate acreage of land to be disturbed or uncovered
1.2
6. Person to contact should sediment control issues arise during land -disturbing Cell Phone Number
activity 336-215-3941
Bill Arndt
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Email Address
[e-mail]

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Bowtie Properties LLC
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Name
Current Mailing Address
650 Kingstree Road
Salisbury, NC 28146
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S. Recorded in Deed Book Number
Name
Current Mailing Address
Page Number
1400 693
Part B
1. Person or Firm who are financially responsible for this
land -disturbing activity
Bowtie Properites LLC
Name of Person(s) or Firm(s)
Current Mailing Address
650 Kingstree rd
Salisbury NC 28146
Phone Number
Person or Firm who are financially responsible for this
land -disturbing activity
Name of Person(s) or Firm(s)
Current Mailing Address
Phone Number
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704-636-5505
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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
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Current Mailing Address Current Mailing Address

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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
Current Mailing Address Current Street Address
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Telephone Number Telephone Number
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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
WilliaVn D4VIJ Eller Ow.�►ee / s�R��«
Signature Date
I, Annr Alc- IUdUir , a Notary Public of the County of ' MZ4xt-✓1 State of North Carolina,
hereby certify thatbOt I I iyIn !t, dvial EJU f appeared personally before me this day and being duly sworn acknowled$g�,ed
that the above form was executed by him/her. Witness my hand and seal of Notary, this 15''-day of �� , 20%
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Notary My commission expires `�`��� M.0
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