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HomeMy WebLinkAboutNCC230630_FRO Submitted_20230310Pitt County �' Planning Department Development Services Building 1717 W. 5th Street �C Greenville, North Carolina 27834-1696 Telephone: (252) 902-3250 James F. Rhodes, AICP Director Fax: (252) 830-2576 Financial Responsibility / Ownership Form Soil Erosion and Sedimentation Control Ordinance No person may initiate any land -disturbing activity on one or more contiguous acres as covered by the Act before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Pitt County Planning Department. (Please type or print and, if question is not applicable, place N/A in the blank.) Part A. 1. Project Name CMi Plastics 2. Location of land -disturbing activity: County Pitt City or Township Ayden , and Highway/Street Pepsi Wa„y, off NC 11 __ 3. Approximate date land -disturbing activity will be commenced: Feb. 2023 4. a Purpose of development (residential, commercial, industrial, etc.): Industrial Approximate acreage of land to be disturbed or uncovered: 6 Acres 6. Has an erosion and sedimentation control plan been filed? Yes X No 7. Person to contact should sedimentation control issues arise during land -disturbing activity: Name_ Steven Hasselbach Telephone 252-746-2171 _ Landowner(s) of Record (Use blank page to list additional owners) Hasselbach Management, LLC Name(s) Name(s) 222 Pepsi Way 222 Pepsi Way Current mailing address Street Address Ayden NC 28513 Ayden NC 28513 City State Zip City State 252-746-2171 252-746-2171 Telephone 9. Recorded in Deed BookNo. 2291 Part B. 1 Telephone Page No. 833-837 Zip Person(s) or firm(s) who are financially responsible for this land -disturbing activity (Use the blank page to list additional persons or firms): Hasselbach Management, LLC Steven Hasselbach Name of Person(s) or Firms (s) Name(s) 222 Pepsi Way 222 Pepsi Way Current mailing address Street Address Ayden NC 28513 Ayden NC 28513 City State Zip City State Zip 252-746-2171 252-746-2171 Telephone Telephone 2. (a) If the Financially Responsible Party is a Corporation, give name and street address of the Registered Agent. Name(s) Current mailing address Street Address City State Zip City State Zip Telephone Telephone (b) If the Financially Responsible Party is a Partnership give the name and street address of each General Partner (Use blank page to list additional partners): Name(s) Name(s) Current mailing address Current mailing 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/her 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. �v6u-CtA5 Type or print name.��, Title or Aut unity 7 nature Date 1, it avi L. Fars' r a Notary Public of the County of \70+ State of Nort Carolina, hereby certify that Stubheri �o��lua ilV1S511�C1n 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 Z 1 day of Dec-embev . 2011. Notary My commission expires Qft,bev 3,UZ�