NCC231992_FRO Submitted_20230707

WILSON
NORTH CAkOt`'
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)
Field Name Description Comments
PROJECT Tracking
number Bartlett Job No.23-122
Complete Application Received date
Application/NOI
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521,Residential,
SIC Code(Primary) 1542 other than SFE(30000)= 1522,others=blank
Project or Site name 2612 Wilco Blvd.S.
Site Street Address 2612 WILCO Blvd.S.
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27893
Non-Government=POF(default)
Government-County =CNG
Government-Federal=FDF
Site/Facility Type of Government-Municipal=MWD
Ownership POF Organization Government-State=STF
Approximate Activity
Start Date Summer 2023
Total Acres of
Distrubance 9.5
FRO-First Name Roy **MUST be Financially Responsible Owner Person**
FRO-Last Name Harrington **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name RCF Investments,LLC **MUST belong to Financially Responsible Owner**
FRO-eMail Address [e-mail] **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address P.O.Box 234 **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text N/A **MUST belong to Financially Responsible Owner**
FRO-Mailing City Wilson **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27894 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.688
Longitude:Decimal
Degrees -77.907

WILSON
(#)ACRES TO BE DISTURBED 9.5 X$150.00/ACRE=$1425.00
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.)
In case of a violation please list the preferred contact(either the Financially Responsible Person or Registered Agent on the line
below:
Roy Harrington 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 white 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.)
014 — 3
Date
Owner
Ttti Authority
c�-
Signat
Roy Harrington
Type or Print Name
AR\16CLVALS a Notary Public of the County of 113GV1 State of North Carolina
hereby certifies
t401 -Ack Y(Y\r -\V f 1 personally appeared before me this day and under oath acknowledged that the
above form was executed by hlit
ti
Witness my hand and notary seal,this Ld day of a•, ZO�3
(Notary Public) t"t o t�� ?ivy
'
HMuoti at t
My commission expires 1\AO 134', �7- AAy North DPW**
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