NCC221449_FRO Submitted_20220413

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 NIA in the blank.)
Part A.
- . - - -:ate , j Tf W.�i�
Z Location of land -disturbing activi: County City or Township 6teeellyWe
Highway/Street7016 5oxiv Latitude3 } , 06�_� j jLongitude --TJ', 3 ..
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
B. Amount of fee enclosed: $ NtA . 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 V" No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name_ &A & E-mail Address i1&Jkd 4 7q whAA • C h-
Telephone S - i q - ` 105 Cell # 2"5? gill • 01; S- Fax # 4k
9. Landowner(s) of Record (attach accompanied page to list additional owners):
(� cm ify -ltb
Name Telephone
Fax Number
11go (Tob N. Wemes f
Current Mailing Address Current Street Address
(A U St INC 17133K 664"ai NL
City State Zip City State Zip
10. Deed Book No. Page No. Allk Provide a copy of the most current deed.
Part B.
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):
e�►6 i!� ewtllL� �k ® vtu 1 • (�'
Name E-mail Address
INN r
Current Mailing Address
e Nc P$3
City State Zip
9
Telephone �5� ' 0 i'f—
Current Street Address
4- ISA-M C�
City
Fax Number
State
Zip

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: N l A' _
Name E-mail AdEEf�
dess
IJ N jk
Current MailinAddress Current Street Address
`` A
WA
City State Zip City State Zip
Telephone _ N 1 + 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:
064 14' k
Name of Registered Agent E-mail Addres
N�11-
Current Mailihd Address Current Street Address
A- - - - ��A-
City State Zip City I
�f State Zip
Telephone Iylk 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.
6-J LLi A-[,L—
Type int name
ature
LW18 e (L --
Title or Authority %%
Date
1, N G-a. C. 60 `}%)n , a Notary Public of the County of 'f ,1.4
State of North Carolina, hereby certify that f) c, vil -R Ne1r4V-trk— 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 Z day of _ Nlcr cV% , 201,7,
Notary
NETAASF-ai BOYKIN My commission expires f f - a L( -.2U �5
Notary Public, North Carolina
Pitt County
My Commission Expires
Dove---nber 24 2025