NCC241913_FRO Submitted_20240621

WILSON
NORTH CAROLINA
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)
Field Name ' Description ' I Comments '
PROJECT Tracking
number
Complete Application Received date
Application/N01
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521, Residential,
SIC Code(Primary) 1541 other than SFE(30000)=1522,others=blank
Project or Site name EMCO Wheaton Retail Corporation
Site Street Address 2300 Industrial Park Drive SE
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27893
Non-Government=POF(default)
Government-County =CNG
Government-Federal=FDF
Site/Facility Type of Government-Municipal=MWD
Ownership POF Organization Government-State=STF
Approximate Activity
Start Date June 16,2024
Total Acres of
Disturbance 1.1 ACRES
FRO-First Name James **MUST be Financially Responsible Owner Person**
FRO-Last Name Lawrence **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name EMCO Wheaton Retail Corporation **MUST belong to Financially Responsible Owner**
FRO-eMail Address [e-mail] **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 2300 **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text 2300 Industrial Park Drive SE **MUST belong to Financially Responsible Owner**
FRO-Mailing City Wilson **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27893 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.7013
Longitude: Decimal
Degrees
-77.8911

WILSON
r:r v l pi
(#)ACRES TO BE DISTURBED 1.1 AC X$150.00/ACRE=$165.00
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.)
In case of a violation please list the preferred contact(either the Financially Responsible Person or Registered Agent on the line
below:
James L.Lawrence Ronnie L.Sutton,PE
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.)
05/13/24
Dote
President,CEO
Title or Authority
• j
ignatur
s L.Lawrence
Type or Print Name
311"1Es L 5/14c251
Title Date
11/4 13 1 \<-Q_ lD 1 SSQ'f �- 'L ,a Notary Public of the County of 9 \ .State of North Carolina
hereby'{- certifies
J o,f \es L • Lawrem personally appeared before me this day and under oath acknowledged that the
above form was executed by him. r\
Witness my hand and notary seal,this ) "N day of NACKy a v a L) .
(Notary Public) -
BROOKE C BISSETTE
My commission expires ApT► \ �� 14a5 Notary Public
Pitt Co.,North Carolina
My Commission Expires April 13,2025