NCC232057_FRO Submitted_20230706

6/29/23.11.06 AM 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.
Part A Parcel ID Number
5658-02-56-0396
L.Project Name
Rowan Count RV Dealership-EC23.001
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2.Location of land-disturbing activity(Highway/Street)*
595 E. Ritchie Rd
Latitude Longitude
35°37'35"N -80°29'38"W
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3.Approximate date land-disturbing activity will be commenced
7/17/2023
4.Purpose of development(residential,commercial,industrial,etc.)
Commercial
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5.Approximate acreage of land to be disturbed or uncovered*
33.5
6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity
[phone]
Dave Haskins
°this information will be made available on the Rowan County Planning&Development website.
Email Address
[e-mail]
https://www.rowancountync.gov/FormCenter/Print?formID=96&Preview=YES&Save=False&savedProgresslD= 1/3

6/29/23,11:06 AM Rowan County
7.Landowner of Record Landowner of Record
NC SALISBURY LLC
Name Name
Current Mailing Address Current Mailing Address
25000 ASSEMBLY PARK DR,WIXOM, MI 48393
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8.Recorded in Deed Book Number Page Number
1421 735
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Part B
1..Person or Finn who are financially responsible for this Person or Firm who are financially responsible for this land-
land-disturbing activity disturbing activity
NC Salisbury LLC
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Name of Person(s) or Firm(s) Name of Person(s) or Firm(s)
Current Mailing Address Current Mailing Address
25000 ASSEMBLY PARK DR,WIXOM, MI 48393
Phone Number Phone Number
[phone]
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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
CT Corporation System
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Current Mailing Address Current Mailing Address
160 Mine Lake Ct Ste 200, Raleigh, NC 27615
Phone Number Phone Number
[phone]
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https://www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD= 2/3

6/29/23,11:06 AM 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
Robert Baidas
Current Mailing Address Current Street Address
25000 Assembly Park Dr.,Wixom, MI 48393
Telephone Number Telephone Number
[phone]
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
Chris Davis Vice President
Signature Date
6/29/2023
`
qrn;Chi al)
I, tediCA.- 1140...a?6 .A.,otar,0. Pqslic of the County of Xf yinaity, State o .4.W.)044t-bzoreikt*7
hereby certify that Or\rt $ k appeared personally before m us day n being duly sworn acknowledged,
that the above form was executed by him/her.Witness my hand and seal of Notary,this day of LU
Notary Leda Friech My commission expires
NOTARY1-UULIC-STATE OF MICHIGAN mm/dd/yyyy cjwcyzg
COUNTY OF LIVINGSTON
My Commission Expires 08/20/2028
Acting in the County
Seal
Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist(PDF)
hups://www.rowancountync.gov/FormCenter/Print?formID=96&Preview=YES&Save=False&savedProgressID= 3/3