NCC242821_FRO Submitted_20240913

8/2/24,6:17 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
5770-12-96-6175
1.Project Name*
ARCO-Sheetz Gas Station
2.Location of land-disturbing activity(Highway/Street)*
721 Andrews St. Salisbury, NC 28144
Latitude Longitude
35.681481 -80.415919
3.Approximate date land-disturbing activity will be commenced
4/22/2024
4.Purpose of development(residential,commercial,industrial,etc.)
Commercial
5.Approximate acreage of land to be disturbed or uncovered*
11.01 acres(original)+ .56 acres (additional) = 11.57 acres (total)
6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity*
828-400-2730
CAGE Engineering-Austin Greenhalge
*this information will be made available on the Rowan County Planning&Development website.
https://www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD=916 1/4

8/2/24,6:17 PM Rowan County
Email Address
[e-mail]
7.Landowner of Record Landowner of Record
721 ANDREWS RETAIL OWNER LLC
Name Name
Current Mailing Address Current Mailing Address
101 S. Kings Dr. Ste 200 Charlotte, NC 28204
8.Recorded in Deed Book Number Page Number
1429 26
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
Sheetz, Inc.
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
5700 6th Ave,Altoona, PA 16602
Phone Number Phone Number
[phone]
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
https://www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD=916 2/4

8/2/24,6:17 PM Rowan County
Current Mailing Address Current Mailing Address
2626 Glenwood Avenue, Suite 550
Raleigh, NC 27608
Phone Number Phone Number
[phone]
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
Brian T. Dinges Vice President, Store Development
Signature Date
Commonwealth of Pennsylvania-Notary Seal
08/07/24 LeaAnna Marie White,Notary Public
Blair County
My commission expires November 9,2027
Commission number 1437888
Member,Pennsylvania Association of Notaries
I, L c&tvici NILVr(AA,a Notary Public of the County of State of A CS—a H
hereby certify that Etch) Ti Offl\`c, appeared personally before me this day and being duly sworn acknowledged
that the above form was executed by Mellen Witness my hand and seal of Notary,this day of it-mu y ) ,2024
https://www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD=916 3/4

8/2/24,6:17 PM Rowan County
Notary My commission expires
Seal
Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist(PDF)
https://www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD=916 4/4