NCC224077_FRO Submitted_20221209

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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)
PROJECT NAME: r o �) 1- co L ioW � % U—C.`CW P6�
PROJECT LOCATION: 3ISO S `yhfd n S J U f q w I _.On Pic"
V
APPROXIMATE PROJECT START DATE: S e P ` em er �! 132
(#) ACRES TO BE DISTURBED /a X $150.00 /ACRE=_� I5�• 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.)
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Name (Person or Firm)
3730 No���, A �,; &+Cif,{
Street Address (No P.O. BO1Q� � � � �.b
FtnC h/W i I' f N
City, State, Zip
152- 33oo
Telephone #
IV IA
Fax#,
_C+ C � roD ea� s t erg .e r-a 1 l l c . corn
E-mail address
Registered agent for the person or firm who is financially responsible:
Name (Person or Firm)
Street Address (No P.O. BOX)
City, State, Zip
Telephone #
Fax#
E-mail address
PROJECT NAME: CGOlrO4 Y)o\ PoU LL" 1-0We r R 'I (,LC —(, 4 P p�4

W� LSON
In case of a violation please list the preferred contact (either the Financially Responsible Person or
Registered Agent on the line below:
R i C� � f-d bem; n
Financially Responsible Person
or
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.)
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rifle orAuthority n �1
Signature l C
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I- a,62Z
irtle
Date
a Notary Public of the County of
State North Carolina hereby certifies
personally appeared before me this day and under
oath acknowledged that the above f m was executed by him.
Witness my hand and notary seal, this � day of
(.�r=G
(Notary Public) k
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My commission expiresIP
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