NCC240727_FRO Submitted_20240416

12/12/23, 11:07 AMR owan County
Financial Responsibility/0 w tership Form Sedimentation Pollution Control O(finance
No person m ay initiate any land-disturbing activity on one or m cre acres as covered by the ordinance before this form
and an acceptable erosion and sedim entation control plan have been corn rieted and approved by the Rowan County
Environm eital M aiagem ent Departm et.
Part A Parcel ID Num ber
052-086,-087,-088&-089
0
1.Project Name*
Site Improvements for TA Truck Stop
2.Location of land-disturbing activity(H hway/Street)*
Approx. 1007 Long Ferry Road. Immediately SW of intersection of Long Ferry Rd & Montclair Dr.
Latitude Longitude
Approx. 35 deg. 41' 45" Approx. 80 deg. 24' 22"
3.Approxim ate date land-disturbing activity will be corn m aced
7/3/2024 YYYY
4.Purpose of developm ent(residential,corn m rcial,industrial,etc.)
Propose a 20,000-SF C-Store, an 11,100-SF tractor trailer maintenance building, car pumps, truck pumps,
81 regular parking spaces and 196 tractor trailer spaces.
5.Approxim ate acreage of land to be disturbed or uncovered*
Approx. 25.1-acres.
6.Person to contact should sedim cat control issues arise during land-disturbing Cell Phone Num ber*
activity*
1 [phone]
Dustin B. Johnson, PE
*this information wit be made available on the Row ai County Planning&Development w ebsite.
Em Al Address
[e-mail]
https://www.rowancountync.gov/Form Center/Print?form D=96&Preview=YES&Save=False&savedProgresslD= 1 /3

12/12/23, 11:07 AMR owan County
7.Landowner of Record Landowner of Record
AGS Salisbury, LLC
/ /
Name Nam e
Current Mailing Address Current Mailing Address
12051 Retail Drive, Wake Forest, NC 27587
/
8.Recorded in Deed Book Num ber Page Num ber
052-086: 1412, -087: 1410, -088: 1412, -089: 1412 052-086: 562, -087: 778, -088: 556, -089: 556
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
Harry Singh
/
Nam eof Person(s)or Firm(s) Nam eof Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
12051 Retail Drive, Wake Forest, NC 27587
/
Phone Num ber Phone Num ber
[phone]
/ /
a.If the Financially Responsible Party is not a resident of North Carolina,give nam e and street address of a North Carolina
Agent.
Nam eof Agent Nam eof Agent
/ /,
Current Mailing Address Current Mailing Address
/,
Phone Num ber Phone Num ber
/
https://www.rowancountync.gov/Form Center/Print?form D=96&Preview=YES&Save=False&savedProgresslD= 2 /3

12/12/23, 11:07 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
AGS Salisbury, LLC
•
Current Mailing Address Current Street Address
12051 Retail Drive, Wake Forest, NC 27587
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
ri 01-el CioiM 4r1a9 to, IV(obey
Signature Date 422)24
1, . a otary P,}�blic of the County of � State of North Carolina,
hereby certify th r) 1�appeared personally before me this day_341 being dylysyvorn acknowledge
that the above form was executed by him/ .Witness my hand and seal of Notary,thi day of 7 2
Notary My commission expires
\CUSNCI tiC) Nt4D-
Scat
PAULETTE W. ALSTON
Checklist Notary Public
i-ranklin Co., North Carolina •
ittiyrt++d sofuRtf trine artitatiq gootSedimentation
Cunha Pldn Clwukliat(PDF)
https://www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD= 3/3