NCC222584_FRO Submitted_20220725

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
1. Project Name
Parcel ID Number
408 030 410 001
410 019 410 029
410 112
410 124
Innovation Logistics Center Mass Grading
2. Location of land -disturbing activity (Highway/Street)
331 Pietryk Drive, Salisbury, NC 28146
Latitude
Longitude
35° 36' 20.26"
-80° 31' 03.05"
3. Approximate date land -disturbing activity will be commenced
8/8/2022
4. Purpose of development (residential, commercial, industrial, etc.)
Industrial
5. Approximate acreage of land to be disturbed or uncovered
55 acres x $50/acre = $2,750
6. Person to contact should sediment control issues arise during land -disturbing activity
Cell Phone Number
Chris Urquhart
704-236-2440
Email Address
[e-mail]
7. Landowner of Record
Name
Current Mailing Address
Landowner of Record
Name
Current Mailing Address

8. Recorded in Deed Rook Number
Page Number
454 / 0415, 958 / 940, 741 / 029,
1065 / 649, 837 / 490, 857 / 547
i
Part R
1. Person or Firm who are financially responsible for this land -disturbing
activity
CH-M SELC Peeler, LLC
Name of Person(s) or Firm(s)
Current Mailing Address
4064 Colony Road, Suite 405
Charlotte, NC 28211
Phone Number
704-236-2440
0
Person or Firm who are financially responsible for this land -disturbing
activity
Name of Person(s) or Firm(s)
Current Mailing Address
0
Phone Number
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
Current Mailing Address
Phone Number
0
Name of Agent
Current Mailing Address
0
Phone Number
0
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
CT Corporation System
Current Mailing Address
160 Mine Lake Ct., Suite 200
Raleigh, NC 27615
Telephone Number
919-944-4780
Current Street Address
0
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
prodded herein.

Name
Matt Cochrane
Signature
Title or Authority
Managing Director
I, kLin JrCV/!f a Notary Public of the County of �Lk Ssr��j k State of North Carolina, hereby certify that
A appeared personally before me. this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and seal of Notary, this 77111ny of, 20?X
Nota ry
'v
Seal
BRANDON STEVENS
NOTARY PUBLIC
Me"nburg County
North Carolina
My Commisskm EgIres t. 29, 2023
My commission expires
Sr + . 2: i Zoz