NCC243120_FRO Submitted_20241010

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
060 135 and 060 136
1. Project Name*
Hershey's Ice Cream Distribution Center Expansion
2. Location of land-disturbing activity(Highway/Street)*
710 Corporate Circle-Salisbury, NC
Latitude Longitude
35.641 -80.490
3.Approximate date land-disturbing activity will be commenced
6/30/2024
4. Purpose of development(residential,commercial,industrial,etc.)
Commercial (Freezer Storage Facility Addition)
5.Approximate acreage of land to be disturbed or uncovered*
2.1 Acres

6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity* 717-238-8134 x4215
Matt Ryan, Executive Vice President
*this information will be made available on the Rowan County Planning&Development website.
Email Address
[e-mail]
7. Landowner of Record Landowner of Record
Hershey Creamery Company
Name Name
Current Mailing Address Current Mailing Address
301 S. Cameron St.
Harrisburg PA 17101-2815
8.Recorded in Deed Book Number Page Number
717 485
Part B
I. Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this land-
land-disturbing activity disturbing activity
Hershey Creamery Company
Name of Person(s) or Firm(s) Name of Person(s)or Firm(s)

Current Mailing Address Current Mailing Address
301 S. Cameron St.
Harrisburg PA 17101-2815
Phone Number Phone Number
717-238-8134 x4215
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
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
CT Corporation System

Current Mailing Address Current Street Address
1111
160 Mine Lake Ct. Ste. 200
Raleigh NC 27615
Telephone Number Telephone Number
855-316-8944
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
Matt Ryan
Executive Vice President
it
Signature Date
mm/ddlyyyy
( 6.1,
irg, L) 1/ ,a Notary Public of the County of t1�/1 State of�Nu tCal eli,ia,hereby
certify that IM.4,;l.��ly ti! appeared personally before mett is day and being duly sworn acknowledged that the
above form was executed by htin/her.Witness my hand and seal of Notary,this 5 clay of 1-3Aie ,20.2
N ota My commission expires 1 (i2 Q.Z
r3 k,
mmldd/yyyy
Commonwealth of Pennsylvania.history Seal
Robert J.Campbell,Notary Public
Dauphin County
My commission expires September 25,2026
Commission number 1022522
Member,Pennsylvania Association of Notaries
Seal
Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist(PDF)