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HomeMy WebLinkAboutNCC216807_FRO Submitted_20211208Financial 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 1. Project Name Hwy 152 Mass Grading 2. Location of land -disturbing activity (Highway/Street) 725 E NC Hwy 152 Latitude 35 571744 3. Approximate date land -disturbing activity will be commenced 1 /1 /2022 4. Purpose of development (residential, commercial, industrial, etc.) Industrial 5. Approximate acreage of land to be disturbed or uncovered 154 Longitude -80.555072 Parcel ID Number 5636-02-76-3113 5636-02-65-2566 5636-02-75-6760 5636-02-65-0153 5636-02-85-8815 5636-04-64-8065 5636-04-63-0816 6. Person to contact should sediment control issues arise during land -disturbing activity Cell Phone Number Holden Sabato 1 1 862-222-5899 Email Address holdensabato@silvermangroup.net 7. Landowner ofRecord Landowner ofRecord SL China Grove LLC Name Name Current Mailing Address 195 Morristown Road Basking Ridge, NJ 07920-1650 Current Mailing Address 8. Recorded in Deed Book Number Page Number 1378 / 498, 1378 / 501, 1378 / 502, 1378 / 571, 1378 / 572 Part B 1. Person or Firm who are financially responsible for this land -disturbing activity SL China Grove LLC Name of Person(s) or Firm(s) Current Mailing Address 195 Morristown Road Basking Ridge, NJ 07920-1650 Phone Number 862-222-5899 Person or Firm who are financially responsible for this land -disturbing activity Name of Person(s) or Firm(s) Current Mailing Address Phone Number 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 Current Mailing Address Phone Number Name of Agent Current Mailing Address 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 Corporation Service Company Current Mailing Address 2626 Glenwood Avenue, Ste 550 Raleigh, NC 27608 Telephone Number 1-800-927-9800 Current Street Address 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 Knot 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 Jul aKe it ��� Title or Authority E",-C L� �.(-,I�r Signature Date �t ........................... .............. ..........................,.................................................................. ��,,77 1 J6........... QQ Ncw �l 1, K, 1 a Notary Public of the County of 3p Lapt State ofJie�hereby certify that appeared perso ally bcfoe me tlris dsy and beiu duly sworn acknowledged that the above farm wag evecuted by himfhen Witness my hand and seal of Notary, this day of /VDfpJl!%t•.Y , �ti, Notary Seal LAUREN R INGLESINO Notary Public of New Jersey My Commisslort expires December 13, 2022 Commission # 50073533 Afy commission expires 121131 ZZ