NCC230025_FRO Submitted_20230105

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name 1008 Pender Street S.
2. Location of land -disturbing activity: County Wilson City or Township Wilson
Highway/Street 1008 Pender Street S. Latitude(decimal degrees) 35.710 Longitude(dedmal degrees)-77.908
3. Approximate date land -disturbing activity will commence: Winter 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.7
6. Amount of fee enclosed $1 ,400.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 peracre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Rodger H. Lentz E-mail Address [e-mail]
Phone: Office # 252-399-2210
Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Wilson 252-399-2210
Name
P.O. Box 10
Current Mailing Address
N/A
Phone: Office # Mobile #
112 Goldsboro St. E.
Current Street Address
Wilson NC 27894 Wilson
City State Zip City
10. Deed Book No. 2880 Page No. 330
NC 27893
State Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
City of Wilson
[e-mail]
Company Name
E-mail Address
P.O. Box 10
112 Goldsboro St. E.
Current Mailing Address
Current Street Address
Wilson NC 27894
Wilson NC 27893
City State Zip
City State Zip
Phone: Office # 252-399-2210
Mobile # N/A
Note: If the Financially Responsible Party is not the
owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic
company registered on the NC Secretary of State
business registry, give name and street address
of the Registered Agent:
N/A
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N/A
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Bartlett Engineering & Surveying, PC
Engineering firm or other consultant
Steve Oliverio
Individual contact person (type or print)
[e-mail]
E-mail Address
252-399-0704 520-850-4665
Phone: Office # Mobile #
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Rodger H. Lentz
name
Sign6ture
Assistant City Manager
Title or Authority
�l�r�I ZZ
Date T
I, &er(/lx a Nota Public of the County of lun4—
State of No h Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknoo fledged tha
t
the above form was executed by him/her.
Witness my hand and notarial seal, this Q" day of lr120
Notary ( j /�
My commission expires ►,k 3 �a?
KIMBERLY G. ANDERSON
NOTARY PUBUc
Vvayne NaCwdbllaa
My i
Ex*s March 30, 2027

Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
N/A
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
N/A
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. _ Provide a copy of the most current deed.
Landowner 4 of Record:
N/A
Name Phone: Office #
Current Mailing Address Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
N/A
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
N/A
Company 3 Name
Current Mailing Address
City
Phone: Office #
N/A
E-mail Address
Current Street Address
State Zip City
Mobile #
State Zip
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
N/A
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
Zip
City State Zip City State Zip
Phone: Office # Mobile #