NCC242962_FRO Submitted_20240925

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Rowan Canty
irinanclal 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.
Pert t
Petrel IIt Number
236 126
1.Project Remo•
325 PIPELINE
RECEIVED
2.Loudon of land-disturbing activity/Nigbwe)Strecep S E P 1 3 2021
'325 PIPELINE RD CHINA GROVE NC 28023
Letirade
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35.581390
-80.645760
1.Approaimete date laadd atarbang acdvlty will be commented
19/113/2024
4.Pnrpere efdevelopment trestdeeri.L commente4 industrial,eta.)
Residential
5.Appresimate serene of Mod to be disturbed or uncovered`
!3.559 —
e.Perron to coarecr should rod imeal cnnlrot bsun afire during land-disturbing ac wiry Cell Pboee Number.
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'eft Mennmo oft,M o**to on M Rowan Ceunw MARI. floRkt e*OR
Loma Address
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7.Landowner of Renard Landdowuer of Record
'ION ALAN HARLESS EMILY ANN HARLESS —..
Name Name
Neme
Cerreet MaltlanAddress _ Current MWleg Addrem
325 PIPELINE ROAD ".ya /;f S+
CHINA GROVE,NC 2R023 4535
s, N c z -i
L Recorded In and Rook Number Page Number
t442 306
Part R
I.Person ur Ylrm who are Rnaaeialy responsible for as leeddlsturbtog atrhity Person or Firm wbn err fuesn ally rapaenlbic for rb4 land-dlslerbing activity
TOri, f4:1..etec ttet.L f-I ;S
Name of P arut(s)a Firm(*)
Name of Person(s)vFbm(s)
Current Meiiy Address Cement Palau
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Pbea.Member •beer Member
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a.1f the Pteeedelly Regeealble Parry is nor a resident of North Carew,glre same and street address eta North Cere0ne Agent.
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8127/24,1008 PM
Roam Comet
Nome of Agri.
tun.of Agent
Current Mailing Address Current Mailing Address
Phone Number Phone Number
b.If the Financially Rtrponeible Party is a Partnership or other person engaging in husinest under an assumed name,attach a copy of the certificate of atrumed name If the Financially Responsible Party ten(orporation,give the name and street address of the
Registered.1gent.
Name of Registered Agent
• 4.
Current Mailluu Address Current Street Address
.•
.•
'telephone Nun., Telephone Number
me above Information h Fn.and commt to thy beet of my knowledge and belief and net provided hy me under oath.(This form must be signed by the Financially Responsible Person If au individual or his attrintry-in-fact or if not m Individual by ao ofticer,director.
partner.or registered agent with 11.11111/1ily to raceme instruments for the Financially Responsible Person).I agree to provide correctional information should there he any change in the information presided herein,
home
Tide or Authority
70,1,PLI
Signature Date
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IN4tAnanibitik.Villft:it Notary Public of the Counts of 6243D4r...Mate Csigirth Carolina hereby trrreln th:50, nIACCCIISIS appeared personalty.hekne me this day and being duly sworn neknonledged that the Mom form
was emented Milker.Witness my hand and real of Nola,this tillil.efay of ,200.1
Notary
My commission espires
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Checklist\\41/4,14t..4 § s pori;
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