NCC232826_FRO Submitted_20230920

01/26/23, 1:15 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.
Part A Parcel ID Number
408 011
1.Project Name
Sheetz-Salisbury
2.Location of land-disturbing activity(Highway/Street)
Located south of the intersection of Peeler Rd. &Lane Pkwy.
Latitude Longitude
35.6079 -80.5171
/
3.Approximate date land-disturbing activity will be commenced
3/2/2023
4.Purpose of development(residential,commercial,industrial,etc.)
Commercial
5.Approximate acreage of land to be disturbed or uncovered
8.90
6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number
activity 919-896-2019
Wes Hall
/
Email Address
[e-mail]
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01/26/23, 1:15 PM Rowan County
7.Landowner of Record Landowner of Record
Sheetz Inc.
Name Name
Current Mailing Address Current Mailing Address
5700 Sixth Ave.,Altoona, PA 16602
8.Recorded in Deed Book Number Page Number
1420/480
Part B
1.Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this
land-disturbing activity land-disturbing activity
Sheetz, Inc.
G
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
5700 Sixth Ave.,Altoona, PA 16602
Phone Number Phone Number
919-896-2019
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
Corporation Service Company
Current Mailing Address Current Mailing Address
2626 Glenwood Ave. STE 550, Raleigh, NC 27608
Phone Number Phone Number
866-403-5272
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01/26/23, 1:15 PM Rowan County
b.If the Financially Responsible Party is a Partnership or other person engaging in business under au 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
Steven P. Augustine VP of Store Development
Signature Date
Li. FY
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I, 1, ScS , n'lv rCl" ,a Notary Public of the County of �3lCl r r State of-Ne 4h Ca elma
hereby certify that Steven P. Augustine appeared personally before me this day and being duly sworn acknowledged
that the above form was executed by him/hen Witness my hand and seal of Notary,this 3.13'day of 3clnu cL� " ,20,23
J Notary My commission expires
lD.-a 3--a4
alkAgl fin,L AT.i 4-
Commonwealth of Pennsylvania-Notary Seal
Seal Alissa Morgret,Notary Public
Blair County
My commission expires October23,2024
Checklist Commission numbor 1384847
Download a copy of the Erosion and Sedimentation hiQ'nthar,t�onnuyivsnla Ae000lotion of Notarlos
Control Plan Checklist(PDF)
https://www.rowancountync.gov/FormCenter/Print?formID=96&Preview=YES&Save=False&savedProgresslD= 3/3