NCC231510_FRO Submitted_20230526

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 Parcel ID Number
/.I
1.Project Name*
China Grove Auto Auction
2.Location of land-disturbing activity(Highway/Street)*
Rock Lane
Latitude Longitude
35.572291 -80.547418
3.Approximate date land-disturbing activity will be commenced
2/28/2023
4.Purpose of development(residential,commercia,industrial,etc.)
Commercial
5.Approximate acreage of land to be disturbed or uncovered*
6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity* i
-- ___-- 317-491-0435
David VanVeldhuizen
*this information will be made available on the Rowan County Planning&Development website.
Email Address
[e-mail]
I

7.Landowner of Record Landowner of Record
JJ Kane Associates, Inc.
Name Name
Current Mailing Address Current Mailing Address
33 Inverness Center Pk, Birmingham AL 35224
4
8.Recorded in Deed Book Number Page Number
1412 459
Part B
1.Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this land-
land-disturbing activity disturbing activity
JJ Kane Associates, Inc.
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
33 Inverness Center Pk, Birmingham AL 35224
Phone Number Phone Number
317-491-0435
!o
a.ff 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
Capitol Corporate Services, Inc.
4 _ 4
Current Mailing Address Current Mailing Address
176 Mine Lake CT STE 100, Raleigh, NC 27615
Phone Number Phone Number
800-345-4647
4

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 Street Address
Telephone Number Telephone Number
r —
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
Dennis McIntyre President
Signat Date
mm/dd/yyyy a.—13 -a-6,6?,7:.d(
I,"roe "2C i c1t ,a Notary Public of the County of S Ca'lax y L State of North Carolina,
hereby certify that I)?tvccq S frooift appeared personally before me this day and being dui sworn acknowledged
that the above form was executed by him/her.Witness my hand and seal of Notary,this 13 day of kbilikeLM ,203
Notary M:y commissio, -'rirvr _
mm/dd/ _,q/A�E4'• ROSE REEDY
YYYY :: My Commission Expires
*` "�.� May 28,2025
Seal
Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist(PDF)