NCC223382_FRO Submitted_20220928

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
Dollar General - Salisbury, NC
2. Location of land -disturbing activity (Highway/Street)
TBD Briggs Road - Salisbury, NC
Latitude
I _�5.654467
3. Approximate date land -disturbing activity will be commenced
mm/dd/yyyy August 2022
Longitude
-80.586532
4. Purpose of development (residential, commercial, industrial, etc.)
Commercial
5. Approximate acreage of land to be disturbed or uncovered
2.15 acres
6. Person to contact should sediment control issues arise during land -disturbing
activity
[Joe Strickland - Teramore Construction, LLC
Email Address
[e-mail]
Parcel ID Number
I 465AO43 &
465AO44
Cell Phone Number
704-224-7364

7. Landowner of Record Landowner of Record
Greer Goodman Trustee I
Name IName
Current Mailing Address Current Mailing Address
;f
1070 Mainsail Road - Salisbury, NC 28146
1
S. Recorded in Deed Book Number Page Number
927 & 1209----------'------------- --J� 110 & 581
Part B
1. Person or Firm who are financially responsible for this
hand -disturbing activity
Teramore Construction, LLC
Joe Strickland
Name of Person(s) or Firm(s)
Current Mailing Address
214 Klumac Road Suite 101 - Salisbury, NC 28144'�
Phone Number
Person or Firm who are financially responsible for this
land -disturbing activity
Name of Person(s) or Firm(s)
Current Mailing Address
Phone Number
704-224-7364
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
i
Name of Agent
I
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Current Mailing Address
Phone Number Phone Number
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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
Current Mailing Address Current Street Address
i
Telephone Number Telephone Number
I
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'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).
l agree to provide correctional information should there be any change in the information provided herein.
Name Title or Authority
--- - _.------ --....-.
Joe Strickland Manager
Signature Date
v rR > mm/dd/yyyy
/ .. ) � . :2.19
t,T.;
.; /\ , <- /` - I L, a rotary Public of the County of �� C �,/ . � �� State of North Carolina,
hereby certify that J U � S � �1 K ' appeared personally before me this day and being duly s o n acknowledged
that the above form wa xecuted by him/her. Witness my hand and seal of Notary, this 4rk� ilay of _ / % , 20 'Z.Z
Notary / My commission expires 6 12 5/ Z 6 Z z
x mm/dd/yyyy
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uolss{wuJOO AN
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Seal
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Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist (PDF)