NCC230855_FRO Submitted_20230418

2/24/23, 12:31 PM Rowan County
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.
PartA Parcel ID Number
Z6 ZZ6
1.Project Name*
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2.Location of land-disturbing activity(Highway/Street)*
Latitude Longitude
3.Approximate date land-disturbing activity will be commenced
mm/dd/YYYY Z IZ1Z_3
4.Purpose of development(residential,commercial,industrial,etc.)
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S.Approximate acreage of land to be disturbed or uncovered*
6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity*
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*this information will be made available on the Rowan County Planning&Development website.
Email Address
https://www.rowancountync.gov/FormCenter/Print?fonnlD=96&Preview=YES&Save=False&savedPro,-ressID= 1/3

2/2<P23, 12:31 PM Rowan County
7.Landowner of Record Landowner of Record
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Name Name
Current Mailing Address Current Mailing Address
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S.Recorded in Deed Book Number Page Number
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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
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Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
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Phone Number Phone Number
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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
Current Mailing Address Current Mailing Address
Phone Number Phone Number
https://www.rowancountyne.gov/FormCenter/Print?formID=96&Preview=YES&Save=False&save-dProgressID= 2/3

/24i23, 12:31 PM Rowan County
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
Telephone Number Telephone 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 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
e,,Y) C e r—
Y /
Signature Date
1 mm/dd/yyyy
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.......................................................................................................................................................................................
I,SQ rQ b Anil S. L CL it 2t ,a Notary Public of the County of C a bO r yU State of North Carolina,
hereby certify that SQ-gh C�y K OE appeared personally before me this day and being duly sworn acknowledged
that the above form was executed by him/her.Witness my hand and seal of Notary,this Z`f day of-Fe Y (t V ,20G�
Notary My commission expires
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SealCJ
Checklist U 8
Download a copy of the Erosion and Sedimentation %�-�RRus G�J`�� `
Control Plan Checklist(PDF)
https://www.rowancountync.,-ov/FormCenter/Print?formID=96&Preview=YES&Save=False&savedPro.ressID= 3/3