NCC250494_FRO Submitted_20250217

8/2/24,10:58 AM 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 A Parcel ID Number
133 289
1.Project Name*
KERNS TRUCKING
/.
2.Location of land-disturbing activity(Highway/Street)*
VACANT PARCEL AT THE CORNER OF US HWY 29 (N. CANNON BLVD) AND OLD BEATTY
FORD RD.
Latitude Longitude
35 . 540364 -80 . 601701
3.Approximate date land-disturbing activity will be commenced
mm/dd/yyyy 9 .1.2 0 2 4
4.Purpose of development(residential,commercial,industrial,etc.)
COMMERCIAL
5.Approximate acreage of land to be disturbed or uncovered*
1.64
6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity* 704-692-7036
JOSEPH GRAY
'this Information will be made available on the Rowan County Planning&Development website.
https://www.rowancountync.gov/FormCenter/Print?formID=968,Preview=YES&Save=False&savedProgress[D= 1/4

8/2/24,10:58AM Rowan County
Email Address
[e-mail]
7.Landowner of Record Landowner of Record
ALYSON GRAY JOSEPH GRAY
Name Name
Current Mailing Address Current Mailing Address
128 OAKFOREST DRIVE
KINGS MOUNTAIN, NC 28086
8.Recorded in Deed Book Number Page Number
1442 889
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
ALYSON GRAY
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
128 OAKFOREST DRIVE
KINGS MOUNTAIN, NC 28086
Phone Number Phone Number
704-692-7036
/.
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
https://www.rowancountync.gov/FormCenter/Print?formlD=968Preview=YES&Save=Faise&savedProgresslD= 2/4

8/2/24,10:58 AM Rowan County
Current Mailing Address Current Mailing Address
4
Phone Number Phone Number
4
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
Telephone Number Telephone Number
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
ALYSON GRAY OWNER
Signature Date
mm/dd/yyyy
191 MA
I,03.SWIYIN -Eltaia,Notaq.Public of the County of LJ\QI A1'l(J� State of North Carolina,
hereby certify that P\\ t: ppeared personally before me this day and being du sworn ac owled e L
that the above form was a cuted by him/her.Witness my hand and seal of Notary,this 2 day of 20
https://www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgressID= 3/4

8/2/24,10:58AM Rowan County
Notary My commission expires
mm/dd/yyyy
Seal
Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist(PDF)
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https://www.rowancountync.govlFormCenter/Print?formlD=96&Preview=YES&Savo=False&savedProgressI D= 4/4