SWA000079_2020-11-19 Financial-Responsibility_20201124

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name United Rentals
2. Location of hand-disturbing activity: County Rowan County City or Township
Highway/Street Webb Road Latitude 3511 35' 59.86" N Longitude 8,00 31' 42.09" W
3, Approximate date land-disturbing activity will commence: 1111120
4. Purpose of development(residential, commercial, industrial, institutional, etc.)-. Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.30
6, Amount of fee enclosed: $ 390 . The application fee of$65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7, Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-diisturbing activity,-
Name Jason Wagoner E-mail Address rwagoner(@_ur.corn
Telephone Cell # (33 ) 469-7906 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lloyd and Paula Troxier
Name Telephone Fax-Number
118 Rebel Road
Current Mailing Address Current Street Address
Salisbury NC 28144
City State Zip City State Zip
10, Deed Book No. 0843 Page No. 0473 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet,) if the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible pady.
United Rentals,, Inc. rwag ones(cDur.com
Name E-mail Address
100 First Stamford Place, Suite 700 100 First Stamford Place, Suite 700
Current Mailing Address Current Street Address
Stamford, CT 06902 Stamford, CT 06902
City State Zip City State Zip

Telephone Fax Number
2 (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
United Rentals Realty, LLC [e-mail]
Name E-mail Address
10330 David Taylor Dr. 10330 David Taylor Dr,
Current Mailing Add�meam Current Street Address
Charlotte, NC28262 Charlotte NC28282
City State Zip City S late Zip
Telephone Fax Number
(b) If the Financially Responsible Party is Partnership mr other person engaging in business, under an
assumed name,attach m copy uf the Certificate ofAssumed Name. |f the Financially Responsible Party
iea Corporation, give name and street address cf the Registered Agent:
Name ofRegistered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax 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 rnmmt be signed by the Financially Responsible Person if an individual
or his gftmrney-in-fmot, or if not an individual, by an mfMcer, dinactor, partner, or xsg|etensd agent with
the authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information should there be any change iD the information provided herein.
Irene U4houris Senior Vice President, Treasurer
Type oy.4� AW ama Title orAuthority
1
Signature Date
__________________________________________________________________________
|, , a Notary Public nf the County mf
State of , hereby certify that - G' peGred
personally before me this day and being duly avvmrnuohnovv|edAedthat the above form was�x8Cuted
by him,
Witness nny hand and notarial seal, this day of 20
Notary
STUART N.DOLGIN
' °"=. , � � �^ JpouARxPU8LJC
My commission expires My COMMISSION EXPIRES
NOVEMBER30,20.�,O
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