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HomeMy WebLinkAboutNCC220983_FRO Submitted_20220329Financial 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 matt.erich@trustedcampaigns.com 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 Cki—L- wlc�� - r,A L I ,g ipUBL ��\ -� -- -- — ------ O41)v iCOVg�\' �\ fly commission expires mmlddlyyyy Ol f P-7 1 v20 �k'u