NCC233419_FRO Submitted_20231116

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form and
an acceptable erosion and sedimentation control plan have been completed and approved by the Land Quality
Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if the question is not
applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name: Highland Branch Greenway
2. Location of land-disturbing activity: County Gaston City or Township Gastonia
Highway/Street Rankin Lake Road Latitude 35° 17' 34" N Longitude 81° 10'59"W
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3. Approximate date land-disturbing activity will commence: Spring 2019
4, Purpose of development(residential, commercial, industrial, institutional, etc.): Greenway Trail
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 3.44
6. Amount of fee enclosed: $ 260.00 . The application fee of$65.00 per acre (rounded up to
the next acre)is assessed without a ceiling amount(Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Gary Seine PE E-mail Address: garysCa?_cityofgastonia.com
Telephone [phone] Cell# Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached List
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1, Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
City of Gastonia
Name E-mail Address
PO Box 1748 150 South York Street
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28052
City State Zip City State Zip
Telephone[phone] Fax Number 704-864-9732
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2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) 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 Party is a
Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number I;
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 the
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.
Rusty Bost Director Development Services
Type or print name Title or Authority
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Signature Date
I, MQ,I,i4,4,(x, pc- Okt1.1-0,4_ , a Notary Public of the County of 6 Qs-6
State of North Carolina, hereby certify that Pi I),s'- IDS+ appeared
personally before me this day and being duly sworn acknovledged that the above form was executed by
him.Witness my hand and notarial seal, this F day of Lty`u S-1- , 20 r pp
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