NCC232046_FRO Submitted_20230705

4s6s
NOKIH CARO!INA
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: Op s h6E- 4 wb1- olo Ur
PROJECT LOCATION:33 14 a e-Dr w
APPROXIMATE PROJECT START DATE: I a o a.2
(ti)ACRES TO BE DISTURBED $14 Q X$150.O0/ACRE= , 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.)
R\(\ sarTh Co ►�, n r,��, i r . \nc
Ngnc onJ`ar� )
up-er La 1
State,Zip
T ao u_ "4 Lv,4 c) T
Faxll
i?x YV .t-4-5 e r m
E-nall address
Registered agent for the person or firm who is financially responsible:
Name(Person or Firm)
Street Address(No P.Q.BOX)
•
City,State,Zip
Telephone#
Fax#
E-mail address
PROJECT NAME: ?°F sVveA.t-" V` l Pr-

WILSON
NORTH CAROLINA
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Jam.kre nOSCV or
Financially Responsible Person 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.)
aJa41 3
Date
t7Ok' pera.— (nnS
Tudor uthorlty w
CV,,)
S' a/t�u�re (�
eA +�4t S . TiY1 CA nOcSQ2
Type
t'PokVarpe
opora4ins a J4J3
Title Date
v . e-L. ,a Notary Public of the County of tL( n ` `
,
State of North Carolina hereby certifies
OAL&, e) S. fn C L nosct personally appeared before me this day and under
oath acknowledged that the above form was executed by him.
Witness my hand and notary se. is_ day of c-L r u IA.A
(Notary Publi )AfA
My commission expires k`1 O /
$�`'Q\', D. 04F,,ICS ,�
\-\OTAR ;0?
U