NCC241629_FRO Submitted_20240529

•p: •. a Gaston County
g ._~� Gaston Natural Resources Department
c� Aitt 1303 Dallas-Cherryvate Hwy. Dallas. N.C. 28034 Telephone [phone]
,�aH•• ..�tSoil Erosion & Sedimentation Control
' Financial ResponsibilitylOwnership
airvil
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 (ll1Z 60f.I {S
2. Location of)and-disturbing activity
City 60,5tiwi�l1 Highway/Street untevt 12 f BCC
lhi Pri
Latitude 35. 104'1 Longitude -$(• I319 AA
3. Approximate date land-disturbing activity will commence rl 241.E
4. Purpose of development (residential, commercial, industrial. etc.) 60Wiwl CNG14
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 1. I
6. Amount of fee enclosed S 3200 05
7. Soil Erosion & Sedimentation Plan Filed? Yes t_r Enclosed Li_ Not "
8. Landowner(s)of Record(Use blank page to list additional owners)
Gi R Pr ry, Tw (a/ate-bpi sG
Name / Narne
12 d4u k Z+ VA.sivvr4 P./ 5oo 102 1-1 d-uv-04403 (L d,sic104
Mailing Address Mang Address
O 4 ifim NL Ze o;7- Cm_ Nli 2i3�
City State Zip COState Zip
(/04-) 'CO - S 000 q 1$• 6650
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deeds)�nstrument(s) are recorded
Deed Book 5450 Page OOP
Deed Book _ Page
10. Tax Map No. lg251( Block Lot No.
Page 1

PART B_
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity. NOTE. if FRP is not the
Landowner of Record Part A: B., include with this form the landowner's signed and notarized wrtten consent for the
applicant to submit a draft erosion and sedimentation control plan and to conduct the anticipated land disturbing
activity
li (4 w-brasc 1 tk. (4,62 . 'Oisc
Name Contact Name for Inspection Reports
101 44 614114 P( 'vrto 114, 5k to4 Q7I 4 l , t# 4
Street and Mailing Address E&o+)
ail Address
CV6A4c4A skit no32 tl3 - 5(oSo
City State Zip Telephone Number
oaf) eil • 6650
Telephone Number Fax Number
n street
If the Financially Responsible Party is not a resident of North Carolina. give the name and st eet
address of a North Carolina agent.
Iv --
Name
Street and Mailing Address Email Address
Cty State Zip Telephone Number
3. If the Financially Responsible Party is a Partnership or other person engaging it business under
an assumed name. attach a copy of the certificate of assumed name. If the Financially
Responsible Party is a corporation. give the name and street address of the Registered Agent.
Name
Street and Mailing Address Email Address
it./4 to Lt •J (\,(t_ L S,Z j�-� ��f ��, Sa
City State Zip Telephone Number
A4. The above information is true and correct to the best of my knowledge and belief and was
provided by me under oath. (This foam 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 authonty to execute instruments for the financially responsible person). I
agree to provide corrected information should there be any change in the information provided
herein.
I ( .E, , 1 1, ,L,_.—
Type or Print N to Title or Authority
-2 1 6 '2'1
Signature Date
I, a r:c CIS �,�,1�4 {t 1 a fsotary Public of the County of ��
� � . State of North
Carolina. hereby certify thC�rk l_arm r«., L1;.x appeareWpersonally before me this day
and being duly sworn acknowledged that thE above fo w s executed by him:
Witness my l �a}�nnd notarial seal. this day of 2(�.Q
I
[4, lL1,tl:Lr-ti,
NotarySinn Eires
CARRIE C. BUMGARNER
NOTARY PUBLIC
Gaston County, North Carul;na
My Commission Expires 01 24 2029 Page 2