NCC223706_FRO Submitted_20221031

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)
PROJECT NAME: Project Cascade
Lot 10B Wilson Corporate Park Lamm RD
PROJECT LOCATION: (35' 44' 23 . 49"N, 780 00' 11. 73 "W)
APPROXIMATE PROJECT START DATE: 10 / 1 / 2022
(#) ACRES TO BE DISTURBED 41 . 00 X $150.00 /ACRE= 6,150
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.)
Wilson County Properties, Inc.
Name (Person or Firm)
PO BOX 728
Street Address (No P.O. BOX)
Wilson, NC 27894
City, State, Zip
252-237-1115
Telephone #
Fax#
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
Jennifer Lantz
Name (Person or Firm)
PO BOX 728
Street Address (No P.O. BOX)
Wilson, NC 27894
City, State, Zip
252-237-1115
Telephone #
Fax#
[e-mail]
E-mail address
PROJECT NAME: Project Cascade

In case of a violation please list the preferred contact (either the Financially Responsible Person or
Registered Agent on the line below:
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.)
September 13,2022
Date
Corporate Secretary
Title or Authority
Signature
Jennifer J Lantz
Type or Print Name
Title Date
If' O a Notary Public of the County of V V 1 4 501�
State of North Carolina1hereby certifies
IV. 1 I�e.r y • L-o-v+z=. nersonally anneared hefnre me this day and under
oath acknowledged that the above form was executed by4+im. k t-1r. I_
Witness my hand and notary seal, this - day of S d"1 C Wl ke r 2D�.,2
i
(Notary Public) r
My commission expires Ma aoa -21