NCC230207_FRO Submitted_20230125

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
407A112,407A113,
407AO99
PEACH ORCHARD COMMERCE CENTER
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2. Location of land -disturbing activity (Highway/Street)
735 PEACH ORCHARD ROAD
Latitude Longitude
-80.514 35,621
3. Approximate date land -disturbing activity will be commenced
/2/2023
4. Purpose of development (residential, commercial, industrial, etc.)
INDUSTRIAL
5. Approximate acreage of land to be disturbed or uncovered
22.0
Ai
6. Person to contact should sediment control issues arise during land -disturbing Cell Phone Number
activity
BRANDON REISSER
E-mail Address
breisse r@frarn pton. construction
980.583.4398

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PEACH ORCHARD PROPERTY OWNER, LLC
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Name
Current Mailing Address
465 MEETING ST STE 500
CHARLESTON, SC 29403-4961
Name
Current Mailing Address
S. Recorded in Deed Book Number Page Number
1412 304
Part B
1. Person or Firm who are financially responsible for this land -
disturbing activity
PEACH ORCHARD PROPERTY OWNER, LLC
Name of Person(s) or Firm(s)
Current Mailing Address
Person or Firm who are financially responsible for this land -
disturbing activity
Name of Person(s) or Firm(s)
Current Mailing Address
465 MEETING ST STE 500
CHARLESTON, SC 29403-4961
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Phone Number Phone Number
843.579.9400
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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 Name of Agent
CT CORPORATION SYSTEM
Current Mailing Address Current Mailing Address
160 MINE LAKE CT, SUITE 200
RALEIGH, NC 27615-6417
Phone Number Phone Number
843.579.9400

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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
N/A
Current Mailing Address Current Street Address
N/A
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Telephone Number Telephone Number
N/A
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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). 1 agree to
provide correctional information should there be any change in the information provided herein.
Name Title or Authority
�aS1�. C�o�tr U t.C- e
Signature
..........................................................................................
Date
mm/dd/yyyy
1, C cx-j3 h a Notary Public of the County of g State of North Carolina, hereby
certify that JbOA 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 15 day of 00000Atcr , 20=
Notary My commission expires
mm/dd/yyyy,
fol
Seal
Andrew Phelan
Checklist NOTARY PUBLIC
Download a copy of the Erosion and Sedimentation Control Mecklenburg County, NC
Plan Checklist (PDF) F
mmission Expires October 20, 2026