NCC241185_FRO Submitted_20240425

10/23/23,4:29 PM Rowan County
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
402C008
I. Project Name*
Circle K -Julian Rd & Summit Park Drive
2.Location of land-disturbing activity(IIighnay/Street)*
Land-disturbing activity will be performed on the property located at the corner of Julian Road and
Summit Park Drive.
Latitude Longitude
35°37'52.8"N 80°29'15.5"W
3.Approximate date land-disturbing activity will be commenced
mm/dd/yyyy 7/1/2024
4. Purpose of development (residential,commercial,industrial,etc.)
Commercial - Gas Station with convenience store
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5.Approximate acreage of land to be disturbed or uncovered*
1.52 Acres
-
6.Person to contact should sediment control issues arise during land-disturbing activity* Cell Phone Number*
Nathan Tidd 704-319-5686
'this information will be made available on the Rowan County Planning&Development website.
Email Address
[e-mail]
7.Landowner of Record Landowner of Record
Rowan Summit, LLC
Name Name
Current Mailing Address Current Mailing Address
736 Cherry St, Chattanooga, TN 37402
8. Recorded in Deed Book Number Page Number
1246
662
Part B
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Rowan County
1. Person or Firm who are financially responsible for this land-disturbing Person or Firm who are financially responsible for this land-disturbing
activity activity
Circle K Stores
Name of Person(s) or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
2550 W Tyvola Road, Suite 200, Charlotte, NC,
28217
Phone Number Phone Number
1(919) 609-5052
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 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.
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10/23/23,4:29 PM Rowan County
Name of Registered Agent
Mark Ostoits
Current Mailing Address Current Street Address
2550 W Tyvola Road, Suite 200, Charlotte, NC,
28217
Telephone Number Telephone Number
[phone]
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).1 agree to provide correctional information should there be any change in the information
provided herein.
Name Title or Authority
4.040j ,511
oaf
Signature
Date
Imm/dd/yyyy I
•
1, RatnPAa M, ,Sopfl(pAr ,a Notary Public of the County of Ga`4hy?') State of North Carolina,hereby certify that
MAR$ 4• 05T' 1 r,5 appeared personally before a this day and being_ duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and seal of Notary,this 2�t''WW day of t` l tia, ( ,2tla
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Notary NIv commission expires
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Checklist uss(�'UF)
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