HomeMy WebLinkAboutNCC216007_FRO Submitted_20211028FINANCIAL 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 Circle K - NTI Bayswater Greenville - NC.123
2. Location of land -disturbing activity: County Pitt
Highway/Street E. Fire Tower Road Latitude 35°33'24"
City or Township Greenville
3. Approximate date land -disturbing activity will commence: ASAP
Longitude -77°22'04"
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)- 2.1
6. Amount of fee enclosed: $ 300.00 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 Wes Williams E-mail Address wwilliam@circlek.com
Telephone Cell # 919-995-0843 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Firetower OP LLC
Name
1515 Ringling Blvd. Suite 890
Current Mailing Address
Sarasota FL 34236
City State Zip
10. Deed Book No. 3879
Telephone
Current Street Address
City
Page No. 663
rax Numoer
State
Zip
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):
Circle K Stores, Inc. wrice@circlek.com _
Name E-mail Address
1100 Situs Court, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27606
City State Zip City State Zip
Telephone 919-744-6700 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Meredith W. Rice, Jr. Vice President
Type or print name Title or Authority
"Signature Date
F& , a Notary Public of the County of
State of North Carolina, hereby certify that, 1&4` );4A 1,�.�- JL� C.c'.`�i'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 1A day of I �G�ru� t� , 20 �
ROBIN F. ALF6KC ,
NOTARY PUBLIC
Johnston County ota
a►th Carolina
My Gon-Assian I:xpiras April 23.2023
My commission expires