NCC240020_FRO Submitted_20240104

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 Comments
PROJECT Tracking
number Bartlett Job No.22-397
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) 1521 other than SFE(30000)=1522,others=blank
Project or Site name 1158 Place Phase 3
Site Street Address Airport Blvd.W.
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27896
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 Fall/Winter 2023
Total Acres of
Distrubance 9.5
FRO- First Name Rex **MUST be Financially Responsible Owner Person**
FRO-Last Name Vick Jr. **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name RBV 1158,LLC **MUST belong to Financially Responsible Owner**
FRO-eMail Address [e-mail] **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 3434-135 Kildaire Farm Road **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text N/A **MUST belong to Financially Responsible Owner**
FRO-Mailing City Cary **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27518 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.747
Longitude:Decimal
Degrees -77.971

r
WILSO
(#)ACRES TO BE DISTURBED 9.5 X$150.00/ACRE=$1,425.00
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:
Rex Vick Jr. 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.)
i
0
Date
President
A
Title or Authority
Signature
Rex Vick Jr.
Type or Print Name
a Notary Public of the County of ( 5tate of North Carolina
:y certifies
7 � V :personally appeared before me this day and under oath acknowledged that the
above form was executed by him. 2�—y
Witness my han nd nota "I,this day of •7 -
(Notary P blic}
My com is ' n expires
CO MY XPIRES
%y9), �'U LIG
.,��r�14
,M CO )t ' t sA