NCC216402_FRO Submitted_20211123

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Southeast Sewer — Phase 1
2. Location of land -disturbing activity: County Gaston City or Township Varies
Highway/Street Varies Latitude 35014'10.25" N Longitude 81 °03'38.00" W -- FM BEGINNING
35013'32.55" N 81 °04'24.25" W — GRAVITY BEGINNING
35013'02.75" N 81 °03'52.50" W — PUMP STATION
3. Approximate date land -disturbing activity will commence: Fall 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16 acres
6. Amount of fee enclosed: $ Already Paid . The application fee of $65.00 per acre (rounded up
to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8A. Person to contact should erosion and sediment control issues arise during land -disturbing activity FOR
SANITARY SEWER:
Name Jarred Fuller, Fuller & Co. Construction E-mail Address 'arred@_fullerandco.com
fullerandco.com
Telephone [phone] Cell # 980-241-8453 Fax # [phone]
8B. Person to contact should erosion and sediment control issues arise during land -disturbing activity FOR
PUMP STATION:
Name Anthony Grice, Wharton -Smith E-mail Address agrice(@_whartonsmith.com
Telephone [phone] ext. 5302 Cell # 704-965-2621 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Varies — list previously submitted
Name Telephone
Current Mailing Address
City State
Current Street Address
Zip City
State
Fax Number
Zip
10. Deed Book No. Varies Page No. Varies Provide a copy of the most current deed.
DEEDS PREVIOUSLY PROVIDED

Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Curtis R. Bost, City of Gastonia rustyb(a�cityofgastonia.com
Name E-mail Address
PO Box 1748
Current Mailing Address Current Street Address
Gastonia NC 28053-1748
City State Zip City State Zip
Telephone [phone] Fax Number 704-867-0120
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
n
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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 name and street address of the Registered Agent:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip City State Zip
Fax 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
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Curtis R. Bost Director of Development Services
Type or print name Title or Authority
Signature Date
I, iw� ;Str_ 1(fe4z-� , a Notary Public of the County of (2�a'4nA
State of North Carolina, hereby certify that , CAL k's P—_ Ev appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this �` day of 20 Z f
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