NCC230979_FRO Submitted_20230405

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 Parcel 10 Number
407 014
407 015
407 115
1.Project Name
Henderson Grove Industrial
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2.Location of land-disturbing activity(Highway/Street)
1475 and 1477 Henderson Grove Church Rd, Salisbury, NC 28147
Latitude Longitude
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350 62' 50.00" -800 51' 00.00"
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3.Approximate date land-disturbing activity will be commenced
4/1/2023
4.Purpose of development(residential,commercial,industrial,etc.)
Industrial
5.Approximate acreage of land to be disturbed or uncovered
$200 plan review fee + 53 acres x $125/acre = $6,825
6.Person to contact should sediment control issues arise during land-disturbing activity Cell Phone Number
Brooke Bures 512-202-6589
Email Address
[e-mail]
7.Landowner of Record Landowner of Record
ELLER THOMAS O ETAL SHUE NANCY BOSTIAN
Name Name
Current Mailing Address Current Mailing Address
PO BOX 1765 710 PEACH ORCHARD RD
SALISBURY, NC 28145 SALISBURY, NC 28147

8.Recorded in Deed Book Number Page Number
DB 784#831, DB 784#831, DB 802#669
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Part B
1.Person or Firm who are financially responsible for this land-disturbing Person or Firm who are financially responsible for this land-disturbing
actin ity activity
TC MidAtlantic Development V, Inc
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
888 16th Street, NW I Suite 555
Washington, DC 20006
Phone Number Phone Number
512-202-6589
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
Current Mailing Address Current Mailing Address
Phone Number Phone Number
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
Corporation Service Company
Current Mailing Address Current Street Address
2626 Glenwood Ave Ste 500,
Raleigh, NC 27608
Telephone Number Telephone Number
1-800-927-9800
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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 b)an officer,director,partner,or registered agent with authority
to execute instruments for the Financiall)Responsible Person).1 agree to provide correctional information should there be any change in the information
provided herein.

Name c Title or Authority
Signature Date
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D1S'i�yCToF GOI.UMgrlq
1,R&ODdrm S.COOK ,a Notary Public of the eunmPdt• hereby certify that
CAhAMIL S Tki 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 L day of Rbfl)Q"Wr,20j3
Notary � � My commission expires
/So 12202-+
Seal
ALEXANDRA S.COOK
Notary Public,District of Columbia
,`,,,1,tt1ttnrtrttt)t,, My Commission Expires 1150/2027
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