NCC233452_FRO Submitted_20231128

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more contiguous 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 Department. (Please type or print and,if question is not applicable,
please place N/A in the blank)
PART A.
1. Project Name Taco Bell—Fire Tower Road(Covengton Downe BIock G,Lot 2)
2. Location of land-disturbing activity:Township Winterville Township
3. Approximate date land-disturbing activity will be commenced: 12/1/2023
4. Purpose of development(residential,commercial,industrial,etc.)
Commercial
5. Approximate acreage of land to be disturbed or uncovered: 0.87 Acres
6. Has an erosion and sedimentation control plan been filed? Yes X No
7. Person to contact should sediment control issues arise during land-disturbing
activities. Ken Malpass
8. Landowner(s)of Record(Use blank page to list additional owners)
Sound Bank -
Name(s)
4051 S.Memorial Drive,Suite B -
Current Mailing Address Current Street Address
Winterville,NC 28590 -
City State Zip City State Zip
4109 819
9. Recorded in Deed Book No. 4159 Page No. 193
ai Hi he deeded to Plains Coastal ,. Aoper ley Y�>*., 4:i..t<I£ t_? ;e _ days
PART B.
1.(a)Person(s)or firm(s)who are financially responsible for this land-disturbing activity
(Use blank page to list additional persons or firms)
Coastal Plains Restaurants,
c/o Mr.Scott Hitnmelfarb -
Name(s)
3205 Bismark Street -
Current Mailing Address Current Street Address
Greenville NC 27834 -
City State Zip City State Zip
Telephone [phone] Telephone -

2.(a)If the Financially Responsible Party is a Corporation give name and street address of
the registered agent.
(Name)
Mailing Address Street Address
City State Zip City State Zip
Telephone Telephone
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.
Scott Himmelfarb Director of Operations
Ty se or .rint name Title or Authority
�gnature `.� if `�-�
Date
I,Wit I tQn„ C- d W.Wig,$ ,a Notary Public of the County of i t t
State of North Carolina,hereby certify that .5'c,;,ti` t-iimetivi E 1 r ,
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 the-3014 day of C r-11)1aer ,2023
o
,�,> il Notary
: p` ,. F`t. ' , My commission expires Ot> 1 CI /aoa�
NOT s�_
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