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Financial Responsibility/Ownership Form Sedimentation Pollution Control Ordinance

  1. 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.

  2. Part A

  3. Name

  4. Name

  5. Part B

  6. Name of Person(s) or Firm(s)

  7. Name of Person(s) or Firm(s)

  8. a. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of a North Carolina Agent.

  9. 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.

  10. 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.

  11. I, _________________________, a Notary Public of the County of _________________________ State of North Carolina, hereby certify that _________________________ 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 _____ day of _______________, 20__.

  12. Seal

  13. Leave This Blank: