NCC221096_FRO Submitted_20220328

Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion &Sedimentation Control
x
�1 Financial Responsibility/Ownership
No person may initiate any land -disturbing activity on one (1) or more acres of property in all portions of
Gaston County, except for that property within the city limits of the incorporated municipalities of Gaston
County who have not adopted the Gaston County Soil Erosion & Sedimentation Control Ordinance,
before this form and an acceptable Soil Erosion & Sedimentation Control Plan have been completed and
approved by the Gaston County Natural Resources Department's staff.
PART A: (Please type or print and, if question is not applicable, place NIA in blank)
1. Project Name Depalo Foods
2. Location of land -disturbing activity
City Belmont Highway/Street 2010 The Oaks Parkway
3. Approximate date land -disturbing activity will commence October 2021
4. Purpose of development (residential, commercial, industrial, etc.) Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 4
6. Amount of fee enclosed S_1,200
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Else blank page to list additional owners)
E
10.
2010 Oak Parkway LLC
Name
19233 Stable Ford Lane
Mailing Address
Cornelius NC 28031
City State Zip
704-363-2825
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 4441 Page 1451
Deed Book Page
Tax Map No. 183622 Block
Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
2010 Oak Parkway LLC
Name
19233 Stable Ford Lane
Mailing Address
Cornelius NC 28031
City State Zip
704-363-2825
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
If the Financially Responsible Party is not a resident of North Carolina, give name and street
aUUMSS 03 a rv0fLH Carolina a ent.
Name
Mailing Address Street Address
City State Zip Telephone Number
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 Part is a Corporation give name and street address of the Registered Agent.
Name
Mailing Address Street Address
City State Zip Telephone Number
4. 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).
agree to provide corrected information should there be any change in the information provided
herein.
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Responsibility -Ownership Form.mw
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