NCC222221_FRO Submitted_20220624

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I/ Gaston County
�4 Gaston Natural Resources Department
4 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion & Sedimentation Control
s
o a
N 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
3.
4.
5.
5.
Project Name Delta Drive Storage Facility
Locatioof land :disturb ng activity
City astonta, Ne Highway/Street Delta Drive
Approximate date land -disturbing activity will commence January 2022
Purpose of development (residential, commercial, industrial, etc.) Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas) +/- 4 Acres
Amount of fee enclosed $ $1,200
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
1651 Delta Drive 11, LLC
Name
101 N. Tryon St. 9629
Mailing Address
Charlotte NC 28246
City State Zip
[phone]
Telephone Number
0
10
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 5276 Page 967-969
Deed Book Page
Tax Map No. 224357
Block Lot No.
Page t

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
1651 Delta Drive II, LLC
Name
101 N. Tryon St. # 629
Mailing Address
Charlotte NC 28246
City State Zip
9( 80}_580-0069 _
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 anent.
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.
Hemal Badiani
Name
101 N. Tryon St. # 629
Mailing Address Street Address Charlotte NC 28246 (980 ) 5$0-0069
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.
Hemal Badiani CEO
Type or Print Name Title or Authority
Signature Date
a Notary P blic of the County of Slate of North
CaroTina, hereby certify that Q (1.4 appeared personally befdre me this day
nd being duly sworn acknowledged that the above form was executed by him.
fitness my hand and D rial seal, this 1 (3(- day of u ,'24[ .
Notary SEAL My Commission Expires
DENISE E CLARK File: Financial Responsibility -ownership Form.mw
Notary Public
Mecklenburg Co., North Carolina
My Commission Expires Dec. 18, 2021 Page 2