NCC222357_FRO Submitted_20220628

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before
this form and an acceptable erosion and sedimentation control plan have been completed and approved
by the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or
fax information unavailable, place N/A in the blank.)
Part A. R
1. Project Name -Rockwell ABC Store
2
3.
4.
5.
6.
7.
Location of land -disturbing activity: County Rowan City or TownshipRockwell
Highway/Street320 East Main StLatitude35.549131 Longitude-80.402828
Approximate date land -disturbing activity will commence:June 27, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas)- 1.52
Amount of fee enclosed: $(200) (500) The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameTerry Osborn E-mail Address [e-mail]
Telephone[phone] Cell # 704-633-1641 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ROWAWKANNAPOLISALCOHOLICBEVERAGECONTROL BOARD 704-633-1641 704-633-1666
Name
PO BOX 114
Current Mailing Address
Salisbury, NC 28145
City State Zip
10. Deed Book No. 1 394 Page No.
Telephone Fax Number
510 N Lee St
Current Street Address
Salisbury, NC 28144
City State Zip
150 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
ROWAN/KANNAPOLISALCOHOLIC BEVERAGE CONTROL BOARD [e-mail]
Name
PO BOX 114
Current Mailing Address
SALISBURY, NC 28145
City State Zip
Telephone [phone]
E-mail Address
510 N Lee St
Current Street Address
Salisbury_ , NC 28144
City State Zip
Fax Number704-633-1666

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:
n/a
Name
n/a
Current Mailing Address
n/a
City
Telephone n/a
n/a
E-mail Address
n/a
Current Street Address
n/a
State Zip City State Zip
Fax Number n/a
(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 name and street address of the Registered Agent:
n/a
Name of Registered Agent
n/a
Current Mailing Address
n/a
City State Zip
Telephone n/a
n/a
E-mail Address
n/a
Current Street Address
n/a
City State Zip
Fax Number n/a
(c) In order to facilitate Express Permitting, It Is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Summey Engineering Associates, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
Christian Vestal 336-328-0902 336-328-0922
Individual contact person (type or print) Telephone Fax 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 attomey-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.
Terry Osborne
Type crint ame
Signature
St"ate of North Carolina, hereby certify that
before me this day and being duly sworn ai
Witness my h ;jr
jtdt�irial seal, this
Seal �'
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General Manager
Title or Authority
Date
a Notary Public of the County of &w�
f t t d S 6 d If,l k- appeared personally
+vied d that the above form was executed by him.
day of .20 Z Z
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