NCC240927_FRO Submitted_20240410

PLAN REVIEW/FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
CATAWBA COUNTY CODE OF ORDINANCES, CHAPTER 16 ARTICLE V
SOIL EROSION AND SEDIMENTATION CONTROL
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 Catawba County
Utilities and Engineering Department. (Please type or print, and if question is not applicable,please N/A in the blank)
PART A
1. Job Name r Pepsi-Cola Bottling Company Addition
2. PIN or 911 Address I 2793466942
3. Purpose of development(residential, commercial, industrial, institutional,etc.)r Industrial
4. Approximate soil disturbance date r—May 2024
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas) r4.2
6. Has an erosion and sedimentation control been filed? E Yes I- No X Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes x No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name l RICK "3-721065 E-mail address I 13 o fie4 e p lacy. l Co '
Telephone [phone] Cell # I 'gig- 3 p2.- /4 O Fax #
9. Landowner(s) of Record(attach accompanied page to list additional owners)
Name Pepsi-Cola Bottling Company of Hickory Telephone [phone] Fax # v
Current Mailing Address P.O Box 550
City Hickory State I NC Zip 28603
Current Street Address 2401 14th Avenue Circle NW
City I Hickory State I NC Zip 128601
10. Deed Book No. [T142 Page No. [ 712
PART B
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on attached sheet):
Name 1 Pepsi-Cola Bottling Company of Hickory E-mail address 1 J a}/ e_e_4 t r pc rs' ky. CQ't
Current Mailing Address 1 P.O Box 550
City Hickory State NC Zip [ 28603

Current Street Address I 2401 14th Avenue Circle NW
City I Hickory State I NC Zip 28601
Telephone I [phone] Fax# I
2. (a)If the financially responsible party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent: NA
Name I E-mail address I
Current Mailing Address I
City I State I Zip
Current Street Address
City I State I Zip
Telephone I Fax#
2. (b) If the financially responsible party is a Partnership or other person engaging in business under assumed name,
attach a copy of the Certificate of Assumed Name. If the financially responsible party is a Corporation, give name
and street address of the Registered Agent: NA
Name I E-mail address I
Current Mailing Address
City I State I Zip I
Current Street Address I
City I State I Zip I
Telephone j Fax# I
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 the authority to execute instruments for the financially responsible person). I agree to
provide corrected information should there be any change in the information provided herein.herein.
JA>i1
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T , or Print N Title of Authority
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Signatui� Date
I, Jan.vati4t 14 .farrier ,a Notary Public of the County of Cal d wC I I State of North
Carolina,hereby certify that may Teei4er appeared personally before me this day and being duly
sworn ackngyladgo tip the above form was executed by him.
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Win 43 hand and n•',A deal,th•is Cp day of I 1 Qt-c 1'1 20a'1
_ Notary ''
y ik/B L\G .;•E My Commission expires q I 10 I aoa(.o
, Print Form
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