NCC222240_FRO Submitted_20220621

°� Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
s
Stormwater
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 Stormwater Ordinance, before this form and an
acceptable Stormwater Plan have been completed and approved by the Gaston County Natural
Resources Department's staff.
(Please type or print and, if question is not applicable, place N/A in blank)
PART A:
1. Project Name Hans Kissle Southeast Facility
2.
3.
4.
5.
6.
Location of land -disturbing activity
City Dallas Highway/Street Apple Creek Parkway
Approximate date land -disturbing activity will commence 06/21 /22
Purpose of development (residential, commercial, industrial, etc.) Industrial
Total acreage disturbed or uncovered (including off -site borrow and waste areas)
Amount of fee enclosed $ 8750.00
7. Soil Erosion & Sedimentation Plan Filed? Yes No X
8. Landowner(s) of Record (Use blank page to list additional owners)
Na61e� fo Co N o iAt-U l�n�l
Mg Address
TilinD . Ric 1�7t
City State Zip
C 01-SOW,O / Mc- 201�z
Telephone Number 70_ 6 _ -)6 Z
7d 7
Name
Mailing Address
City State Zip
Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 95 Page 128
Deed Book Page
10. Tax Map No. Block Lot No. 9 _
Parcel Number: 306935
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
Name Nut-,
(� /e C, U, , t- -C
Mailin Address
6- k .t4t-&-�F r rr
City State Zip
�&et-&' ff ki e (PiI
Telephone Number �/J� _ �-6_ V100
Contact Name for Inspection Reports
Email Address
Telephone Number
Fax Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent.
Name
Mailing Address Street Address
City State Zip Telephone Number
3. 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). I
agree to provide corrected information should there be any change in the information provided
herein.
Type or Print Name
Signature
M
Title or Auutt+h I '
J
Date
(�OLSS. a Notary Public of the County of
fArissACH4sETTs-gareiina, hereby certify that SO criT M oQFc iT _ appeared per
and being duly sworn acknowledged that tfle above form was executed by hin
Witnes m hand and notarial seal, this �"'� day of A A 2 ®aZ
_ L / 2L ,'?mac
Notary SEAL My Comnfissio6 Expire
File: Financial

Gaston County
" - Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
�... Soil Erosion & Sedimentation Control
N4 �pv
4
I Financial Responsibility/Ownership
It
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.
(Please type or print and, if question is not applicable, place NIA in blank)
PART A:
1. Project Name Hans Kissle Southeast Facility
2. Location of land -disturbing activity
City Dallas Highway/Street Apple Creek Parkway
3. Approximate date land -disturbing activity will commence 06/21/22
4. Purpose of development (residential, commercial, industrial, etc.) Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 24.7
6. Amount of fee enclosed $ 7500.00
7. Soil Erosion & Sedimentation Plan Filed? Yes No X
8. Landowner(s) of Record (Use blank page to list additional owners)
Na e 1I
rk,S+ k GnlkIF G
Mailing Address
P161 OCA It7r
City State Zip
Nc zgo
Telephone Number p 1 E—.85 Z
Name
Mailing Address
City State Zip
Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 95 Page 128
Deed Book Page
10. Tax Map No. Block Lot No. 9
Parcel Number: 306935
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Na ZLS
lcsmPoLnC
Mailing Address
q OOyk Drrye
City State Zip
II u� ► f� r:7-Iq - ©li�z
Telephone Number 97� _ E36
Name
Mailing Address
City State Zip
Telephone Number
If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a Norin C;arollna a
3. 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). I
agree to provide corrected information should there be any change in the information provided
herein.
f Lr cc�v
Type or Print Name Title or Authority
J�/Z /ZL
Signs ure Date
��F i 2 tC r r1 __,SAIqbtary Public of. the County of G SSA , St
o hereby certify that 50a i AAoFFr ,' appeared personAbefand being duly sworn acknowledged that th%above form was ex cuted by him.
Witn hand and notarial seal, this °' day of m � - 2LaZ
Notary SEAL My Commission Expires
File: Financial Resp,