NCC233576_FRO Submitted_20231205

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more 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 the question is not applicable or the e-mail address or
phone number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Shoppes at Arlington Phase II
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Highway/Street Dickinson Avenue Latitude(decimal degrees) 35.594493 Long itUde(decimal degrees)-77.40426
3. Approximate date land-disturbing activity will commence: December 1st, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3 acres
6. Amount of fee enclosed: $ 300.00 . The application fee of$100.00 per acre or portion
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre
application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nicholas Fitzgerald E-mail Address [e-mail]
Phone: Office# 252-565-1023 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Goess Holdings, LLC
Name Phone: Office# Mobile#
3615 Memorial Drive 3615 Memorial Drive
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville NC 27834
City State Zip City State Zip
10. Deed Book No. 004369 Page Na 500 Provide a copy of the most current deed.

i
,
(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.
Company DBA Name
The above information is true and correct to the best of my knowle,dge 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.
GANN.C. Gt 55
Ty or print name Title or Authority
Signa _t _ _-- ,101
, A Date 8 `—:
I, Veiyb ' (a,_ L' (V; )11n �c , a Notary Public of the County of F i^�-
State of North Carol' a, ereby certify that CI 4 t 5 F �jl)2.5s appeared personally
before me this day an eing duly sworn acknowledged that the above form was executed by him/her.
aik
Witness my hand and notarial seal, this oZ day of pf aiu S+ , 20 9.3
����Illloirity� 117401.es.
��,vP,0r11CA 4 i,,,' Notary
�= NO?, Z MMy commission expires i I p , aiD 7
/01111

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).
Goess Holdings, LLC
Company Name E-mail Address
3615 Memorial Drive 3615 Memorial Drive
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville NC 27834
City State Zip City State Zip
Phone: Office# Mobile#
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:
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:
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)