NCC222668_FRO Submitted_20220725

Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
-.'10 A& Soil Erosion & Sedimentation Control
r
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.
(Please type or print and, if question is not applicable, place NIA in blank)
PART A:
2
4
0
0
Project Name Summit Medical Office Building
Location of land -disturbing activity
City Gastonia, NC Highway/Street Summit Crossing Place
Approximate date land -disturbing activity will commence May, 2022
Purpose of development (residential, commercial, industrial, etc.) Medical Office
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 2.80 Ac
Amount of fee enclosed $ 900.00
Soil Erosion & Sedimentation Plan Filed? Yes No x
Landowner(s) of Record (Use blank page to list additional owners)
Name
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Mailin�� /gA/ddress /
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City State Zip
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 5294 Page 665
Deed Book Page
10. Tax Map No.
225545
Block
Lot No.
Page i

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
2a Moe C_
Name
e
-!
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M�a}iling Address
City State Zip
Telephone Number
Name
Mailing Address
City State Zip
Telephone 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
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,
v aC,..d-
Maaiiling Address Street Address
City State Zip 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).
agree to provide corrected information should there be any change in the information provided
herein.
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Type or/Print Name Title or Adt crlty
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Carolina, hereby certify that
it®f d being d savor. acknow ged that e,above
Ov1► Nl, , Less my han and n tarial seal, t day
�Qfq$ Notary_ EAL
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Date
is of the County of State of North
r, ­— , appeared liersonally before me this day
form w s executed by h1'
of
My Commission Expires
File Financial Responsibility -Ownership Form.mw
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