NCC222150_FRO Submitted_20220610

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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.
2.
3.
4.
5.
Project Name BFC Allen Road
Location of land -disturbing activity: County Pitt City or Township Greenville
Highway/Street Allen Rd. Latitude 35.5971 Longitude-77.42222
Approximate date land -disturbing activity will commence: June 1, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25 acres
6. Amount of fee enclosed: $ 2500.00 . The application fee of $100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
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 Scott T. Anderson, P.E.
Telephone [phone]
E-mail Address scott(a)_arkconsultinggroup.com
Cell # 252-258-0734 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BFC Allen Road, LLC
Name
2045 East Gate Dr, Suite D
Current Mailing Address
Greenville NC 27858
City State Zip
252-758-1081
Telephone Fax Number
2045 East Gate Dr, Suite
Current Street Address
Greenville NC
City
State
27858
Zip
10. Deed Book No. 4158 Page No. 00740 Provide a copy of the most current deed.
4158 00751
Part B.
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):
BFC Allen Road, LLC [e-mail]
Name E-mail Address
2045 East Gate Dr, Suite D 2045 East Gate Dr, Suite D
Current Mailing Address Current Street Address
Greenville NC 27835 Greenville NC 27835
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
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 by any change in the information provided herein.
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Type or print name Q
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Title or Authority
Signature Date
I, loom 1OY_(AP1CV&tt a Notary Public of the County of }Pi tt
State of North Carolina, hereby certify that i I I IIAW ejl 1 Gij H t, �. appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this F I day of M Gl 20 2 Z
`ORY PICA-e� 0;1 Nota
Sealy
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