NCC233581_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 Division. (Please type or print and, if the question is not applicable or the e-mail
and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name 2109 Arlington Blvd Commercial
2. Location of land-disturbing activity: County Pitt County City or Township Greenville
Highway/Street Arlington Blvd Latitude 35°36' 12.8" Longitude 77°24'43.9"
3. Approximate date land-disturbing activity will commence: September 2022
4. Purpose of development(residential, commercial, industrial, institutional,etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and wasteareas): 2 Ac
6. Amount of fee enclosed: $ 200.00 The application fee of$100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount(Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes _ No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Edwards E-mail Address [e-mail]
Telephone [phone] Cell#[phone] Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Desai Partners, LLC 252-864-1737
Name Telephone Fax Number
119 Cape Fear Drive 119 Cape Fear Drive
Current Mailing Address Current Street Address
Chocowinity. NC 27827 Chocowinity. NC 27827
City State Zip City State Zip
10. Deed Book No. 4374 Page No. 546-555 Provide a copy of the most current
deed.
Part B.
1. Person(s) or firm(s)who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Desai Partners. LLC imdevanqeyahoo.com
Name E-mail Address
119 Cape Fear Drive 1128 Independence Blvd
Current Mailing Address Current Street Address
Chocowinity., NC 27827 Chocowinity,. NC 27827
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name. attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Devanci Desat
E-mail Address
119 Cape Fear Dr.
Current Mailing Address Current Street Address
Chocowinity NC 27817
City State Zip City State Zip
Telephone_2528641737 Fax Number
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
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there by any change in the information provided herein.
Devang Desai Operating Manager
Type or print name Title or Authority
ature Date
I, \ (-Nti1r4kr..\ • t � , a Notary Public of the County of 1J 114
State of North Carolina, hereby certify that \(\ n !JC!cz,L1. appeared
personally before me this day and being duly swornnowledged that the above form was
executed by him.
Witness my ha`�i d �i ,seal, this day of f/ , 20
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