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HomeMy WebLinkAboutNCC231132_FRO Submitted_20230425 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 WAWA - #6104 2101 Stanstonburg Road 2. Location of land-disturbing activity: County Pitt County City or Township Greenville Highway/Street 2101 Stantonsburg Road Latitude 35.60526 Longitude -77.40149 3. Approximate date land-disturbing activity will commence: 2101 Stantonsburg Road 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.24 acres 6. Amount of fee enclosed: $235 . 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 Collice Moore E-mail Address collicemoorejr(a�gmail.com Telephone 252-341-0500 Cell# 252-341-0500 Fax# 9. Landowner(s) of Record (attach accompanied page to list additional owners): Tilco Investments LLC 252-341-0500 Name Telephone Fax Number 4300 Sapphire Ct Ste 116 4300 Sapphire Ct Ste 116 Current Mailing Address Current Street Address Greenville, NC 27834 Greenville, NC 27834 City State Zip City State Zip 10. Deed Book No. 4275 Page No. 133 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): Collice Moore collicemoorejr©gmail.com Name E-mail Address 4300-116 Sapphire Ct 4300-116 Sapphire Ct Current Mailing Address Current Street Address Greenville NC 27834 Greenville NC 27834 City State Zip City State Zip Telephone 252-341-0500 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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. Collice Moore, Jr. Manager Type or print name Title or Authority �.c_./ 01/12/2023 Signature C" Date I, 7L, �L zi hCti Vl ► tenon , a Notary Public of the County of State of North Carolina, hereby certify that CoIk1CP Moore, V • 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 14- day of JL-fUQ,L , 20 r Notary My commission expires J 2 15 2027 4.1 ..t.l ll1;i}i ,\