NCC222510_FRO Submitted_20220713

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
t. Project Name
ERICH SITE - PERFORMANCE ROAD
2. Location of land -disturbing activity (Highway/Street)
0 PERFORMANCE ROAD
Latitude Longitude
35°33'47.45"N 80'43'53.09W
3. Approximate date land -disturbing activity will be commenced
2/1 /2022
4. Purpose of development (residential, commercial, industrial, etc.)
LIGHT INDUSTRIAL
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5. Approximate acreage of land to be disturbed or uncovered
2.3
Parcel ID Number
239-086
6. Person to contact should sediment control issues arise during land -disturbing Cell Phone Number
activity ' 317-435-9781
,MATTHEW ERICH
Email Address
[e-mail]

7. Landowner of Record
Landowner of Record
MATTHEW ERICH
Name
Current Mailing Address
1121 OLD CONCORD RD, SUITE 1
SALISBURY NC 28146
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Name
Current Mailing Address
8. Recorded in heed Book Number Page dumber
1372/ 127
Part B
1. Person or Firm who are financially responsible for this
land -disturbing activih
MATTHEW ERICH
Name of Person(s) or Firm(s)
Current Mailing Address
1121 OLD CONCORD ROAD, SUITE
SALISBURY, NC 28146
Phone Numhcr
Pet -son or Firm who are financially responsible far this
land -disturbing activih,
Name of Person(s) or Firm(s)
Current Mailing Address
E�
Phone Number
317-435-9781
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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
-Name of Agent
Current Mailing Address Current Mailing Address
Phone Dumber 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
Cut -rent Nfailing Address Current Street Address
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
MATTHEW ERICH ©INNER
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Signature Date
mm! /ddlyyyy
1, *t �' t MCA\( a Notary Public of the County of '?-\ o v.tOr. State of North Carolina,
herebycertitj, that Mega-]r1„pvJ tiUh appeared personally before me this day and being dull- s8vorn acknowledged
that the above form was executed by him/her. Witness my hand and seal of Notary, this Wtdday of jA%nvc,a_ , 2024-
Notary
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