NCC223803_FRO Submitted_20221110

PLAN REVIEWIFINANCIAL RESPONSIBILITY/OWNERSHIP FORM
CATAWBA COUNTY CODE OF ORDINANCES, CHAPTER 16 ARTICLE V
SOIL EROSION AND SEDIMENTATION CONTROL
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 Catawba County
Utilities and Engineering Department. (Please type or print, and if question is not applicable, please N/A in the blank)
PART A F-&9k- 09-rX21 _ c�8C*
1. Job Name ! Tree Brand Packaging
2. PIN or 911 Address 1 2800 Wood Tech Drive
3. Purpose of development (residential, commercial, industrial, institutional,etc.) Industrial
4. Approximate soil disturbance date 10/15/21
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 19.5 AC.
6. Has an erosion and sedimentation control been filed? r Yes r No 5Z Attached
7. If you have an Erosion Control billing account, would you like this to be billed? 1— Yes j)7 No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Chris Helms E-mail address [e-mail]
Telephone [phone] Cell # 1704-622-7899 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name Tree Brand Packaging, Inc. Telephone [phone] Fax # N/A
Current Mailing Address 7971 Graham Road
City Denver State NC ZipF8037-806
Current Street Address I Same as Above
City
State
10. Deed Book No. 3663 Page No. F-O-9-15-
Zip
PART B
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on attached sheet):
Name Tree Brand Packaging, Inc. E-mail address [e-mail]
Current Mailing Address 7971 Graham Road
City Denver State NC Zip 28037-806

Current Street Address
Same as Above
City
State
Zip
Telephone [phone] Fax # N/A
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:
Name I N/A ' E-mail address
Current Mailing Address
City I State I Zip
Current Street Address
City State Zip
Telephone Fax #
2. (b) If the financially responsible party is a Partnership or other person engaging in business under assumed name,
attach a copy of the Ceirtificate of Assumed Name. If the financially responsible party is a Corporation, give name
and street address of the Registered Agent:
Name Alfred H. Helms E-mail address [e-mail]
Current Mailing Address 7971 Graham Road
City Denver State NC Zip F28037-806
Current Street Address I Same as Above
City I State Zip
Telephone [phone]
Fax # I N/A
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 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.
Type a . ring Zne � Title of Autliority
Signature Date
I, t;�4 i C _\� C'. a Notary TUC f
Carolina, hereby certify„t{tat, (` i � r
sworn acknowled a�� ,tom +' ,irm w s executed by him.
Witness my ha_ 0t mdk1, phis * - day of-L
Seal ZE
of O_aAr1_W(36L1 State of North
appeared personally before me this day and being duly
r , 20d
Notary
My Commission expires
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