NCC231446_FRO Submitted_20230515

PART B:
1. Person(s) or firm(s)who are financially responsible for this land-disturbing activity
T'i'srfa
a Name
5ZQ crl- a7)6u614V.ZPIr S
Mailing Addr s Mailing Address
neA .1\.t. Ate. ZA )514
City State Zip City State Zip
14 -8°4 — 3.511-
Telephone Number 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
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 Title or Authority
Signature Date
I, t i flvlQ , V vUW a Notary Public of the County of f 9Cb l fl h tir State of North
Carolina, hereby certify that ur Sa1.2h 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 t day of 7ginuctn, 20a3
n •_— ,,I�, ,�,� r•fl., ANQUANETTE V ,OLF,E.r�1,
1J�1C$l�l/�/W Alf, v�N,1 Sr Notary Public, North .,® 1 �.�1 00(3
Notary ;';�}}}w:F3 S'EALlenburg CoMyt C mnlission Expires
My Commission Expires File: Financial Responsibility-Ownership Form.mw
Page 2

°°UNr� Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
4t- 84 'Cr
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 Gateway Center
2. Location of land-disturbing activity
City Mt Holly Highway/Street 210 Beatty Drive
3. Approximate date land-disturbing activity will commence April 2023
4. Purpose of development(residential, commercial, industrial, etc.) Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 18.22 AC
6. Amount of fee enclosed $ $5,700
7. Soil Erosion & Sedimentation Plan Filed? Yes_✓ No
8. Landowner(s) of Record (Use blank page to list additional owners)
Regional Developers LLC
Name Name
520 Eagleton Downs Drive,Suite D
Mailing Address Mailing Address
Pineville NC 28134
City State Zip City State Zip
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 089 Page 023
Deed Book 5292 Page 0409
10. Tax Map No. Block Lot No.
Page 1