NCC220983_FRO Submitted_20220329

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
ERICH SITE - PERFORMANCE ROAD
2. Location of land -disturbing actiNih ([li tlnvas Street)
0 PERFORMANCE ROAD
Latitude
35'33'47.45"N
3. Approximate date land -disturbing acti.ity -ail) he cntnnrenced
2/1 /2022
l .tut„ itude
80'43'53.09W
g. Purpose of dc%elopmenl tresiden6al_ contntcreial. industrial. de.)
LIGHT INDUSTRIAL
S. ipnrttsintare arreare of hand to he dixturhed ur itncuceretl
2.3
Forced 11) Number
239-086
6. Persou to contact should sedimetil control issues ar isr durimg (and-tikiuritin_ C'01 Phone Number
activit-
317-435-9781
MATTHEW ERICH
Email address
[e-mail]

7. Landowner of Record
MATTHEW ERICH
Name
C urn,-w Mailing Addrt•ss
1121 OLD CONCORD RD, SUITE 1
SALISBURY NC 25146
S. Recorded in Deed Boot: Numbet-
1372/127
l.:urdn« ner of Record
Name
Currew Mailing address
Page \umber
1. Person or Firm who are financially responsible for this Person or Firtn who are financially responsible for this
land -disturbing activity Lind -disturbing actin ity
MATTHEW ERICH
Name of Person(s) or Firm(s) Name of Person(s) or Firms)
Current itlailin; Address Current flailing Address
1121 OLD CONCORD ROAD, SUITE1
SALISBURY, NC 28146
Phunc Number Phouc Number
317-435-9781
a. Ifthe Financially Rcrponsihle Part, is not it resident of North name and sfl•cet address of a North ( m-ohna
Agent_
N:unc of \ cot \:uuc of t�rnt
Current Flailing Address
Phone lumber
Current Mailing Address
Phone Number

h. If the Financially Respunsihlc Pat -IN, is a Partnership or other person em„ arinr in husiness under an assumed name. attach
a cop)• of the certificate of assumed name. If the Financially Responsible Part% is a Corporation, give the name and street
address of the Retrictered A,_,ent-
Name of Re!,istcred Agent
Current Mailing Address Current Street kddress
Telephone i\umher lclephone Number
The above information is true and correct to the hest of my knomledge and belief and %%a5 pi-mided hN me under oath. ('Phis
form nmst he signed by the Financially Re<ptm dhle Pet•cnn if an individual nr hi< atttn ne)-in-fact or Knot an individual by
an officer, director. partner, or re.3istered aocnt with authority to execute instruments for the Financially Responsible Person).
I agree to provide correctional information should there be an) Chan-e in the inrortnation provided herein.
Name Title or Luthorit%
MATTHEW ERICH OWNER
Si ;nature
Date
mm/dd/yyyy
........./..................................................................................................................................................................................
I, 1rl )i t IAt,►Q V Notary Public of the (. ountv of oLJct,rs, State of North Carolina.
hereby' certitk. that 'E.;cM� appeared pvr%onafh before rile this da% and heing duh%%corn acknowledged
lhat the above torn) was executed by hin)'her. «imcss lily hand and seal of Notati, this 12L�'da)' of Llnv3U�d
Nutary
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