NCC216807_FRO Submitted_20211208

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
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
[e-mail]
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