NCC222745_FRO Submitted_20220801

Gaston County
Gaston Natural Resources Department
\dam J 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
a. r_
..tvStormwater
% 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 Stormwater Ordinance, before this form and an
acceptable Stormwater Plan have been completed and approved by the Gaston County Natural
Resources Department's staff.
PART A:
1.
2.
3.
4.
5.
6.
(Please type or print and, if question is not applicable, place NIA in blank)
Project Name Truck Training Facilty, 3051 Aberdeen Boulevard
Location of land -disturbing activity
City Gastonia Highway/Street Aberdeen Boulevard
Approximate date land -disturbing activity will commence January 2022
Purpose of development (residential, commercial, industrial, etc.) vocational
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 3.92
Amount of fee enclosed $ 1,400.00
7. Soil Erosion & Sedimentation Plan Filed? Yes x No
8. Landowner(s) of Record (Use blank page to list additional owners)
a
10
Jamestown Bob,LLC
Name
2730 Rozzelles Ferry Rd.
Mailing Address
Charlotte, NC 28208
City State Zip
7t y 3C-5_� Zd to I
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 5274 Page 140
Deed Book Page
Tax Map No. PID3's 137846 8 137845
Block
Lot No.
Page I

PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
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Name -?
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Mailing Address
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Cit State Zip
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Telephone Number
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Contact Name for Inspection Reports
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Email Addre_s
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Telephone Number
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Fax 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
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).
agree to provide corrected information should there be any change in the information provided
herein.
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Type or Print Name Title or Authority
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Signature Date
I, Eli �_�eeo-- , a Notary Public of the County of 1 _ra" /� State of North
Carolina, hereby certify that 4 r hi' r.JP_,iti L-`," f,4 J;- appeared personally before me this day
and being duly sworn acknowledged that the above f rm was executed by him.
Witness my hand and notarial seal, this � day of IMP[. , 2 C,1-/ .
Notary LI• } tA_M ad SEAL My Commission Expires
File: Financial Responsibility -Ownership Form.mw
ELIZABETH M. SPEED
NOTARY PUBLIC
Linooln County
North Carolina Page 2
My Commission Expires June 22, 2025

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