NCC232993_FRO Submitted_20231009

micleal
Gaston County
r
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
_
ie4q
,. , 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 A-1 Storage Expansion Plan
2. Location of land-disturbing activity
City Stanley _ Highway/Street Lucia Riverbend (HWY 16)
3. Approximate date land-disturbing activity will commence
4. Purpose of development(residential,commercial, industrial,etc.) Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 9.6 acres
6. Amount of fee enclosed $
7. Soil Erosion&Sedimentation Plan Filed? Yes X No
8. Landowner(s)of Record(Use blank page to list additional owners)
Canoie McClain on behalf of Stanley Owner, LLC
Name Name
One Financial Plaza, Suite 1700
Mailing Address Mailing Address
Hartford, CT 06103-2601
City State Zip City State Zip
704 .654 .7538
Telephone Number Telephone Number
(Contact. Daniel Renckens on behalf of SafeNeet Construction Manager, LLC)
9. Indicate Deed Book and Page where deed(s)or instrument(s)are recorded
Deed Book Page
Deed Book Page
10, Tax Map No. 214964, 221132 Block Lot No.
Page I

PART B:
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity
Stanley Owner, LLC
Name Name
One Financial Plaza, Suite 1700
Mailing Address Mailing Address
Hartford, CT 06103-2601
City State Zip City State Zip
704 .654. 7538
Telephone Number Telephone Number
1
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent.
Corporation Services Company
Name
2626 Glenwood Ave Ste 550
Mailing Address Street Address
Raleigh, NC 27608
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, 5Sa gafaitk
Type o rint Name Title or Author
I e Date
I, �n
ipIr,t't•O tp. . a Notary Public of the County of 4,i nC o�r� , State of North
Carolina, hereby certify t C A•,F,s 1 . WWYlc Cr0.af\ 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 a., ,day of 6c,plorytilLI,24722- -
ego. +� Sum Io 2&Z-?
otary -, . My Commission Expires
GOLDIE Q ENGLAND File Financial Responsibility-Ownership Form,mw
Notary Public-North Carolina
Lincoln County
My Commission Expires Jun 6,2027 Page 2