NCC221973_FRO Submitted_20220526

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 eros on and sedimentation control plan have been completed and approved by the Rowan County
Environmental Management Department.
Part A
1. Project Name
Dollar General - Salisbury, Old Mocksville Road
2. Location of land -disturbing activity (Highway/Street)
[TBD Old Mocksville Road
Parcel ID Number
325 005
Latitude Longitude
35.705828 ------------------------ 80.465725 -----
3. Approximate date land -disturbing activity will he commenced
7/1 /2022
4. Purpose of development (residential, commercial, industrial, etc.)
Commercial
:5. Approximate acreage of land to be disturbed or uncovered
1.60
6. Person to contact should sediment control issues arise during land -disturbing
activity
Joe Strickland —
Email Address
------------------- -- -
�[e-mail]
Cell Phone Number
704-224-7364

7. Landowner of Record
Teramore Development, LLC
Name
Current Mailing Address
PO Box 6460
Thomasville, GA 31758
8. Recorded in Deed Book Number
Part B
1. Person or Firm who are financially responsible for this
Nand -disturbing activity
FTeramore Construction, LLC —
Name of Person(s) or Firm(s)
Current Mailing Address
214 Klumac Road Suite - 101 — --�
Salisbury, NC 28144
i
Phone Number
704-224-7364 j
Landowner of Record
--------------- —
Name
Current Mailing Address
Page Number
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
i
Name of Agent
Current Mailing Address Current Mailing Address
I
I
Phone Number
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
Current Mailing Address Current S(reet Address
i
I
i
i
Telephone Number 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 if not 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 Title or Authority
Joe Strickland I Member
t
i
I— - -- �.. ---- -- ----- ----� -- — ------------------- --
Signature Date
- ---------mm/dd/YYYY
1, NZL'� L (_ �`i i`*9ry Public of the County of /` �•^ �� State of North Carolina,
hereby certify that C /' S % AG C/C 1-4N/) appeared personally before me this da an jjffmg duly wor �cknowled e
that the above form executed by him/her. Witness my hand and seal of Notary, this
S klay of'_�^, 20
Notary
Seal
Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist (PDF)
My commission expires
d1' L. R ALMAZAN
"6Tp R y PUBLIC
Rowan County
Nort) Carolina
rnissic!7xi�ires June 25, ��