NCC232678_FRO Submitted_20230906

Financial Responsibility/0 w iership Form Sedimentation Pollution Control 0 idinance
No person may initiate any land-disturbing activity on one or m cre acres as covered by the ordinance before this form
and an acceptable erosion and sedim entation control plan have been com pleted and approved by the Rowan County
Environm eital M aiagem ent Departm ent.
Part A Parcel ID Num ber
portion of 366 012
1.Project Name*
Dollar General - Rockwell Store #25502
2.Location of land-disturbing activity(H ghway/Street)*
SW quad at the intersection of Marion Street and Hwy 52 in Rockwell, NC
Latitude Longitude
35.547905 -80.388798
3.Approxim ate date land-disturbing activity will be com m aced
m m dd/yyyy 10/01/2023
4.Purpose of developm art(residential,corn m ecial,industrial,etc.)
Commercial
5.Approxim ate acreage of land to be disturbed or uncovered*
3.82 acres
6.Person to contact should sedim art control issues arise during land-disturbing Cell Phone Num ber*
activity*
704-224-7364
Joe Strickland
*this information w it be made available on the Row m County Planning&Development w ebsite.
Em al Address
[e-mail]

7.Landowner of Record Landowner of Record
Teramore Development, LLC
Name....._..�._w�..__...w�..._....-.__,...._.. Name
......__ ._.....�....._.�
Current Mailing Address Current Mailing Address
PO Box 6460 - Thomasville, GA 31758
8.Recorded in Deed Book Number Page Number
1420 808
Part B
I Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this land-
land-disturbing activity disturbing activity
Teramore Development, LLC
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
214 Klumac Road Suite 101 -Salisbury, NC 28144
Plume Number Phone Number
704-224-7364
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
[ ._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 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
Joe Strickland Registered Agent
Signature Date
1, / Ai`f t' ,a Notary Public Rf the County of ` u`^� 4 State of North Carolina,
here y certify that r= S 'a'ppeared personally before me this dayI, and being duly', worn acknowledged
tha the above form was executed by him/her.Witness my hand and seal of Notary,thisll 7/fllay of ,20 2,3
Notary My commission expires
mm/dd/yyyy J t.1' 2 � 2 U 2 7
DANIE . 1 RAZAN
Seal NOTARY PUBLIC
'owan County, North Carolina
Checklist y Commission Expires June 28,2027
Download a copy of the Erosion and Sedimentation
Control Plan Checklist(PDF)