NCC231816_FRO Submitted_20230613

•
WILSON
NOUN CAROiUNA
Financial Responsibility-Ownership Form
No person may partake in any land disturbing activity within the confines of the City of Wilson Sedimentation and Erosion Control
Ordinance before completing and filing this form with the City of Wilson Erosion Control Division.(*Indicate N/A if a question is not
applicable)
Field Name Description Comments
PROJECT Tracking
number Bartlett Job No.21-663
Complete Application Received date
Application/NOI
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521,Residential,
SIC Code(Primary) 1542 other than SFE(30000)=1522,others=blank
Project or Site name Burrito Shak
Site Street Address 1215 Forest Hills Rd.NW
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27896
Non-Government=POF(default)
Government-County =CNG
Government-Federal=FDF
Site/Facility Type of Government-Municipal=MWD
Ownership POF Organization Government-State=STF
Approximate Activity
Start Date Summer 2023
Total Acres of
Distrubance 0.68
FRO-First Name Chase **MUST be Financially Responsible Owner Person**
FRO-Last Name Riker **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name Shak Ventures,LLC **MUST belong to Financially Responsible Owner**
FRO-eMail Address **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 3330 Jennings Farm Dr.NW **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text N/A **MUST belong to Financially Responsible Owner**
FRO-Mailing City Wilson **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27896 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.739
Longitude:Decimal
Degrees -77.953

WILSON
NORfi CAROi1NA
(#)ACRES TO BE DISTURBED 0.68 X$150.00/ACRE=$102.00
Person(s)or Firm(s)financially responsible for this land disturbing activity:(If out of state,a registered agent in North Carolina
must be used.)
In case of a violation please list the preferred contact(either the Financially Responsible Person or Registered Agent on the line
below:
Chase Riker or
Financially Responsible Person Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by me while under oath.(This
form must be signed by the Financially Responsible Person if an individual or by an officer,director,partner,and attorney-in-fact,
or other person with authority to execute instruments for the financially responsible person if not an individual.)
5/4/!23
Date
Member
Title or A i tir
Signature
Chase Riker
Type or Print Name
2 )A/Vf.P-(d a Notary Public of the County of /GSDN State of North Carolina
hereby certifies
di-4-5-Z.— /e/ personally appeared before me this day and under oath acknowledged that the
above form was executed by him.
Witness my hand and notar seal,this day of /'�/F,�y ?4,2,„3 .
(Notary Public [ �eGe6d
My commission expires#/h .2623 .
Steven Lee Oliverio
NOTARY PUBLIC
Wilson County,l
My Commission Expires 1 23