NCC224061_FRO Submitted_20230104

° Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
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004;�. Soil Erosion & Sedimentation Control
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
Reserve at Rankin Lake
2. Location of land -disturbing activity
City Gastonia, NC Highway/Street Bulb Ave.
3. Approximate date land -disturbing activity will commence February 2022
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)+/- 21 Acres
6. Amount of fee enclosed $ 6,300
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
MCP Northglenn, LLC
Name
40 West 57th Street, Suite 1420
Mailing Address
New York NY 10019
City State Zip
[phone]
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 5344 Page 1625
Deed Book Page
10. Tax Map No. Block Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
MCP NorthWenn, LLC
Name
2626 Glenwood Ave Ste 550
Mailing Address
Raleigh NC 27608
City State Zip
[phone]
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
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.
Mike Ka.vourias
Type or Print Name Title or Authority
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Sign Date
NEyJ yvR�
I, 5 SI L 1 I1j�LI a Nota Public of the County of Af - State offkrrth-
Ca�clu>a� hereby certify that I S appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
VVitn s m and notarial seal, this 29 day of 4 A1601
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N o4 ry SEAL My Commission Expires
File: Financial Responsibility -Ownership Form.mw
SiSILYN UT HIN5
NOTARY PUBLIC, STATE of NO"'
fi jistration No. OtHU643
uallfied in Suffolk County
Ccmmlaalon Ex im March 28, 20