NCC230349_FRO Submitted_20230214

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.� Gaston County
04�40 .W Gaston Natural Resources Department
# 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Stormwater
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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 _ Riverwood Self Storage
I'
3
4
5
6
7
91
10.
Location of land -disturbing activity
City Gastonia Highway/Street Riverwood Parkway
Approximate date land -disturbing activity will commence August 01, 2022
Purpose of development (residential, commercial, industrial, etc.) Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 2.23
Amount of fee enclosed $ 1050.00
Soil Erosion & Sedimentation Plan Filed? Yes X No
Landowner(s) of Record (Use blank page to list additional owners)
JSF Riverwood LLC
Name
100 Dunbar Street
Mailing Address
Spartanburg, SC 29306
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 5382 Page 1027
Deed Book Page
Tax Map No. 209058 Block Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
JSF Riverwood LLC
Name
100 Dunbar Street, Suite 106
Mailing Address
Spartanburg, SC 29306
City State Zip
864-275-8888
Telephone Number
James J. White
Contact Name for Inspection Reports
[e-mail]
Email Address
864-275-8888
Telephone Number
Fax Number
If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina apenL.
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.
James J. White
Name
100 Dunbar Street, Suite 106
Mailing Address Street Address
Spartanburg NC 29306 864-275-8888
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.
Blake W. Spencer CFO
Type r Print Nance Title or Authority
_01 /09/2023
Si nature Date
�r rr
I, [ Za. n a of ry P bl'c the County of ,State of Dla##
Carolina, hereby certify that ppear personally Wore me this day
and being duly sworn acknowledge hair_0g above fo s executed by him.
32-
Comnrission Expires
File: Financial Responsibility -Ownership Form.mw
Page 2

Gaston County
0 JF Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
4� Soil Erosion & Sedimentation Control
Financial Responsibility/Ownership
dCpdRTAf�f+t
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)
1. Project Name Riverwood Self Storage
2. Location of land -disturbing activity
City Gastonia Highway/Street _Riverwood Parkway
3. Approximate date land -disturbing activity will commence August 01, 2022
4. Purpose of development (residential, commercial, industrial, etc.) Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 2.23
6. Amount of fee enclosed $ 900.00
7
EI
101
10
Soil Erosion & Sedimentation Plan Filed? Yes X No
Landowner(s) of Record (Use blank page to list additional owners)
JSF Riverwood LLC
Name
100 Dunbar Street
Mailing Address
Spartanburg, SC 29306
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 5382 Page 1027
Deed Book Page
Tax Map No. 209058 Block Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
JSF Riverwood LLC
Name
100 Dunbar Street, Suite 106
Mailing Address
Spartanburg, SC 29306
City State Zip
864-275-8888
Telephone Number
James J. White
Contact Name for Inspection Reports
[e-mail]
Email Address
864-275-8888
Telephone Number
Fax 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
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.
James J. White
Name
100 Dunbar Street, Suite 106
Mailing Address Street Address
Spartanburg,_ NC 29306 864-275-8888
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.
Blake W. Spencer
Type,Qr Print Name
Si��at�at'e
I, �! L et , a Notary Publ
Carolina, hereby certify that tC
and being duly sworn acknowledged that th qve
Mess my hand and axial al, thi t
CFO
Title or Authority
01 /09/23
Date n
.�I7
the County of �MHXm ZArv.,r State of North
appeared ersonally bebire me this day
-was executed by him.
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Not y MY `C►'s
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Commission Expires
File: Financial Responsibility -Ownership Form.mw
Page 2