NCC223747_FRO Submitted_20221103

Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
14 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
PART A:
1. Project Name Tectonic Industrial
2.
le, place N/A in blan
Location of land -disturbing activity
City Gastonia Highway/Street Mt. Olive Church Road
3. Approximate date land -disturbing activity will commence November 2022
4. Purpose of development (residential, commercial, industrial, etc.) Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
6. Amount of fee enclosed $ 4,800
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
Gastonia Industrial Realty Co
Name
PO Box 876
Mailing Address
Gastonia NC 28053
City State Zip
704-865-9546
Telephone Number
16.00 ac
Name
Mailing Address
City State Zip
Telephone Number
,9 ; . ; , Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Nil- Ned Book 0856 Page 0561
,,beck Book 0866 Page 0587
4 10 -Ta(x Mp No. Block Lot No.
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PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
41ait.e
Name
!o I s. /t,�,�.s br
Mailing Address
ch, �,f e- N� y
City State Zip
7o -�Lo1- o'7,6
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
aaaress of a Ivortn c;aroiina
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). I
agree to provide corrected information should there be any change in the information provided
herein.
Type or Print Name
Signature
IQi,jil�t,s � Title or or Authority
Date
1, & o , a Notary Public of the County of �.k
Carolina, hereby certify that appeared pers
and being duly sworn acknowledged that the above form was executed by him.
Witness y hand and notarial seal, this 2 day of 2� .
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