NCC223248_FRO Submitted_20220923

Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
8a
Soil Erosion & Sedimentation Control
' 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 N/A in blank)
PART A:
1. Project Name ILeonard Greene Limited Partnership
2. Locatipn of Innd-d4stiah ng activity
City Rown of Dallasi Highway/Street Evans Lake Road
3. Approximate date land -disturbing activity will commence September 2022
4. Purpose of development (residential, commercial, industrial, etc.) Multi-Familv Residential Anartmer
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 6.78 ac
6. Amount of fee enclosed $ 2,100
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
Leonard Greene Limited Partnershi
Name
500 S Front St.. 10th Floor
Mailing Address
Columbus n 143215
City State Zip
614-396-3206
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book _5299 Page 2023
Deed Book _ Page
Deed Book _ Page
10. Tax Map No. 169874 1 Block
Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Leonard Greene Limited Partnership
Name
500 South Front Street, 10th Floor
Mailing Address
Columbus, OH 43215
City State Zip
614-396-3206
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.
Paige Pease
Name
16151 Lancaster Highway, Suite B
Mailing Address Street Address
Charlotte NC 28277 704-900-0202
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.
David
Type Q
Signature
, Jr.
Authorized Representative
Title or Authority
6/2/2022
Date
I, Casandra Nicole HutchinsVi , a Notary Public of the County of Franklin , State of Ohio,
hereby certify that David Cooper, Jr. 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 2 day of June 2022
(�4A� pqw�
January 19, 2027
Notary SEAL My Commission Expires
s HUTCH{NSON File: Financial Responsibility -Ownership Form.mw
�: v
WANDRA NICOLE
Notary Public
a —
State of Ohio
rOh 'M
My Comm. Expires
January 19, 2027
O`=
Page 2