NCC222852_FRO Submitted_20220810

Gaston County
Gaston Natural Resources Department
1303 Cherryvilie Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion & Sedimentation Control
'. Financial Responsibility/Ownership
(town",
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 NAM blank)
1. Project Name ' �~
2. Location of Jan -disturbing activity
City Highway/Street
3. Approximate date land -disturbing activity will commence
4• Purpose of development (residential, commercial, industrial, etc-)
5- Total acreage disturbed or uncovered (including off -site borrow and waste areas)' ;
6, Amount of fee Enclosed
7. Soil Erosion & Sedimentation Plan Filed? Yes �o
8. Landowner(s) of Record (Use blank page to list additional owners)
91
10.
Name ]�
Mailing Address
Ci
city State Zip
°Z-
Telephone umber
Name
Mailing Address
city
l-elephone Number
State Zip
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book
—' q page a
Deed Book Page ___
Tax Map No.
Block
Lot No.
Page i

PART B:
1. Person(s) or firms) who are financially responsible for this land -disturbing activity
Name �--
�b LA-0 A(.Z '
Mailing Address
City � State �� Zlp
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
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 Dart is a Corporation give name and street address of the Registered Agent.
Name
Mailing Address Stree Address
to
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 responsibly: 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 Tide or Authori
GG- rA
Signature Date
Aa�
a N tary Public of the County of ,'_W i) ... of North
Carolina, her y certify that e >a , r' / r7 appeared personally before me this day
and being duly sworn acknowledged that the above form wa§ executed by him.
Witn ss my han .and notarial segk�th l t day of ,�_' 20 .
' R
N tary -• � A ER My Commission Expires
O File: Financial Responsibility -Ownership Form.mw
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. Page 2
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