NCC223882_FRO Submitted_20221118

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
I. Project Name
Innovation Logistics Center - Phase 2
2. Location of land -disturbing activity (Highway/Street)
1465 Peeler Rd, Salisbury NC 28146
Latitude
Longitude
Parcel ID Number
406-024, 410-003, 410-
034
35.6039-80.5106
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3. Approximate date land -disturbing activity will be commenced
12/1 /2022
4. Purpose of development (residential, commercial, industrial, etc.)
Industrial
5. Approximate acreage of land to be disturbed or uncovered
32 acres x $125/acre = $4,000
6. Person to contact should sediment control issues arise during land -disturbing Cell Phone Number
activity
704-236-2440
Chris Urquhart
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Email Address
[e-mail]
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7. Landowner of Record Landowner of Record
See Attached Sheet
/. /.
Name Name
Current Mailing Address Current Mailing Address
8. Recorded in Deed Book Number Page Number
Part B
1. Person or Firm who are financially responsible for this
land -disturbing activity
CH-M SELC Peeler II East, L.L.C,
Name of Person(s) or Firm(s)
Person or Firm who are financially responsible for this
land -disturbing activity
Name of Person(s) or Firm(s)
Current Mailing Address Current Mailing Address
4064 Colony Road, Suite 405, Charlotte, NC 28211
Phone Number
704-236-2440
Phone Number
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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
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Current Mailing Address Current Mailing Address
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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
CT Corporation System
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Current Mailing Address
Current Street Address
160 Mine Lake Ct., Suite 200, Raleigh, NC 27615
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Telephone Number
9199444780
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
Matt Cochrane Vice President
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Signature Date
10/12/2022
cJkl, a Notary Public of the County of .5 . iL State of North Carolina,
hereby certify that appeared personally before me this day and being duly sworn acknowledged
that;the abov form was executed by him/her. Witness my hand and seal of Notary, this � day of
2t1
2NotMy commission expires
CHRISTINA L CONKLE
Notary Public, North Carolina
Gaston County
h y—C.9.m_mJ�Sio n_Ex i t s
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August 07, 2027
Seal
Checklist
Download a copy of the Erosi n and Sedimentation
Controt Plan Checklist PDF)

LANDOWNER (CURRENT MAILING ADDRESS (PARCEL
Petter Brown
Carolyn Brown
Christopher Elliott
Gina Elliott
Coy D. Wilhelm
1465 Peeler Road 406 024
Salisbury, NC 28146
140 Cresent Heights Drive 410 034
Salisbury, NC 28146
415 Glover Rd 410 003
Salisbury, NC 28146
DEED PAGE
BOOK NUMBER
1380 724
1311 783
570 582