NCC222805_FRO Submitted_20220805

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 O y ��r1 �i:`o }•
2. Location of land -disturbing activity: County Pi f+ City or Township W1', e4,yi lj,�
Highway/Street QtAnbrooL 17AAC Latitude '&5 • SS'6�l Longitude '%1 •
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): R.GS"Ckrl144&
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): ® • 2S*
6. Amount of fee enclosed: $ 100 . 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 $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name rL010 GLAn r1 E-mail Address Iro6.6tAnnPe VGreoecvr►-I'%z,4-- '�j-4�
Telephone
Cell # 257Z-326" V6$Z Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
&Oaor z6 2.3U-S_692
Name Telephone
Fax Number
H to T Car., ,RA% C'+ S Ct 016 CAC m4rv; t i n 4Ckj'U f
Current Mailing Address Current Street Address
CW
City State Zip
City
State
Zip
10. Deed Book No. ova 3d () Page No. LVbzy 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):
Uellor (AV%4PL.c+'rw, C0� rQ6. IpL.-Nn �GJCrCorGo�kY'�ck►bu •Gs
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip
City
Telephone Z 5 Z' 316 • 1r6 F Z Fax Num
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:
Name
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Num
State Zip
(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
&raw� 14`L ZZP 31
City State Zip City
Telephone 25 Z. • !"- S6 & Z- Fax Number
State Zip
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.
Type or print name
Pros:
Title or Authority
�Z< --,��' /zr/zZ,
Signature Date�
DON \ f. , a Notary Public of the County of V Q.W 1A urn OYeY
State of North Carolina, hereby certify that Z.Oappeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hIs this
T4R y v��
_day of AuW 20 as
8ubtY44�0� Q-9-
Notary
My commission expires an Y i I cm-