NCC242672_FRO Submitted_20240829

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�\ Gaston County
Gaston Natural Resources Department
1 1 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Ne Soil Erosion & Sedimentation Control
•3 Financial Responsibility/Ownership
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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 Gastonia Asphalt Plant
2. Location of land-disturbing activity
City Gastonia Highway/Street Industrial Pike Road
3. Approximate date land-disturbing activity will commence
4. Purpose of development(residential, commercial, industrial, etc.) Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 9 acres
6. Amount of fee enclosed $2,700.00
7. Soil Erosion &Sedimentation Plan Filed? Yes V No
8. Landowner(s)of Record (Use blank page to list additional owners)
Industrial Pike, LLC
Name Name
1451 Delta Dr.
Mailing Address Mailing Address
Gastonia NC 28052
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 5321 Page 0906
Deed Book 4590 _ Page 1544
10. Tax Map No. 307659 Block Lot No.
Page 1

PART B:
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity
Ferebee Asphalt Corp 1
Name Name
PO Box 480066
Mailing Address Mailing Address
Charlotte NC 28269
City State Zip City State Zip
[phone]
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.
Todd Navy
Name
10045 Metromont Industrial Blvd.
Mailing Address Street Address
Charlotte NC 28269 [phone]
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.
David B. Ferebee President
Type orr Print Name Title or Authority
/A14,-e.4.11/' :S-----77:,,-6-..et ,
Signature Date
I, Verra ( .L)Y O a Notary Public of the County-of Y`i12.CL1c- r State of North
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Carolina, hereby certify that iv'idt $.Fer r-1Qe.c., appeared personally bore me this day
and being duly sworn acknowledged that the above form was executed by hi .
W'ness my hand and notarial seal, this l �l r /day of Mira) , 20 -1
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Notary \Co SEAL - My Commission Expires
O 1 A R ), File:Financial Responsibility-Ownership Form.mw
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