NCC230945_FRO Submitted_20230404

12/27/22 5:28 PM Rowan County
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 4 Parcel ID Number
051 036
I.Project Name*
Long Ferry Road Sewer Extension
2.Location of land-disturbing activity(Highway/Street)*
Long Ferry Rd(SR 2120)& Montclair Dr(SR 2183)
Latitude Longitude
35.696267 -80.404076
3.Approximate date land-disturbing activity will be commenced
mm/dd/yyyy March 2023
4.Purpose of development(residential,commercial,industrial,etc.)
Industrial
5.Approximate acreage of land to be disturbed or uncovered*
4.0
4
6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity*
864-237-2285
Mills Brice
4
4
'this Information will be made available on the Rowan County Planning&Development website.
Email Address
mbricea;johnsondevelopment net
4
https://www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD= 113

12/27/22,5:28 PM Rowan County
7. Landowner of Record Landowner of Record
See attached
4 /.
Name Name
Current Mailing Address Current Mailing Address
l h.
8.Recorded in Deed Book Number Page Number
4 X
I
Part B
1. Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this land-
land-disturbing activity disturbing activity
Long Ferry Road Industrial Properties, LLC
/. /.
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
100 Dunbar Street, Suite 400
Spartanburg, SC 29306
4 /.
Phone Number Phone Number
[phone]
4 l
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
X
Current Mailing Address Current Mailing Address
160 Mine Lake Ct, Suite 200
Raleigh, NC 27615
l
Phone Number Phone Number
1
[phone]
4 4
https://www.rowancountync.govlFormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD= 2/3

12/27122,5:28 PM Rowan County
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
l l
Telephone Number Telephone Number
l
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 provided herein.
Name Title or Authority
Iake ti t./. 3pr Cfb
Signature Date
mm/dd/yyyy D o z t7 2 3
.r I .90 444 Cgr^p
State of- �ri1a
a Not r ublic of the County of /k fertireirro}iwe,
hereby certify that ___ 4'appeared personallforeA me this day being d orn acknowledge
that the above form was executed by him per.Witness my hand and seal of Notary,this day of Lt.Q ,20 .47
Notary My commission expires
mm/dd/yyyy T 1 ‘1 1 Z° 3
z:72,
„ ttBER
Seal �,lP /C's
Checklist 3 lGO p��5N I Q Download a copy of the Erosion and Sedimentation 00i2032:
Control Ptan Checklist(PDF) �'� tS\. .•__.-f..0
. p'T,HntC�rxit•
https.11www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD= 3/3

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