NCC231330_FRO Submitted_20230505

C1303°'.!'A Gaston County
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� Gaston Natural Resources Department
j
Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
.*ii°"'i+e Soil Erosion & Sedimentation Control
0� JOG
►,a �w_,,. $ 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 Gaston Commerce Center
2. Location of land-disturbing activity Shannon BradleyRoad
City Gastonia Highway/Street
3. Approximate date land-disturbing activity will commence 03/21/2022
4. Purpose of development(residential, commercial, industrial, etc.) Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 57 acres
6. Amount of fee enclosed $ 17,100
7. Soil Erosion &Sedimentation Plan Filed? Yes X No
8. Landowner(s)of Record (Use blank page to list additional owners)
CKP/C tL 6-74.54vilro.rAmmpaU Cc ., (1.0
Name
45 r .71�arbo ► A, Sl/u-k Name
Mai;i�gd�dress �� g2 I I Mailing Address
41
City 1°L f ' State Zip City State Zip
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s) r instrument(s)are recorded
Deed Book 5'3'9 Page I,05-
Deed Book Page
10. Tax Map No. Block Lot No.
Page 1

PART B:
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity
CRP/CHI Gastonia Commerce Center Owner, LLC Chris Urquhart
Name Name
4525 Sharon Rd, Suite 250 4525 Sharon Rd. Suite 250
Mailing Address Mailing Address
Charlotte NC 28211 Charlotte NC 28211
City State Zip City State Zip
704-236-2440 704-236-2440
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.
CT Corporation Systems
Name
160 Mine Lake Ct., Suite 200
Mailing Address Street Address
Raleigh, NC 27615-6417 704-258-9147
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.
Matt Cochrane Vice President
Type or Print Name Title or Authority
41/1— ,c-( 3/ 9/2 S
Signature Date
I, elQ cat el N. Hof441Q rl , a Notary Public of the County of Iv(ecktem�n"nj , State of North
Carolina, hereby certify that Matt Cochrane appeared personally before me this day
and being duly sworn acknowledged that t e above form was executed by him.
Jtness my hand and notarial seal, this of Marc.-1) 2 Da 3,
fat It �N,N,,,„,,,',,,,,,, i t122 iz o z 5
s ,,
otary i��•,, A �,9y",,My Commission txpires
JQ� .SPRY 's; File:Financial Responsibility-Ownership Form.mw
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