NCC232203_FRO Submitted_20230725

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WILSON
"�R7H CAROLINA
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: ell t0(d ? \ace. IJ-\S
PROJECT LOCATION: CIA D t O.eskt r �-
APPROXIMATE PROJECT START DATE: 2- - 26 - 2O Z3
(#)ACRES TO BE DISTURBED 5; 1 X$150.00/ACRE= 0' CID
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.)
i < <�=Y- \ I i
Name(Person or Firm)
120% Calls o-f NtAivLiact Su,l-I✓201
Street Address(No P.O.BOX)
City,State,Zip
CI 14 Lien -1 C4?
Telephone#
Fax#
-1-YYl( v 1 S @ ICI tt Y4O} C&
E-mail address
Registered agent for the person or firm who is financially responsible:
l cotc-cA.x—D0.v;s
Name(Person or Firm)
T-off 'Falls ©-C -I- a01
Street Address(No P.O.BOX)
c.p lS
City,State,Zip
q (9 - -491 - 0.1 (.463
Telephone#
Fax#
c avts I Q fit{kb`riprl . `sYY-
E-mail address
PROJECT NAME: B C c>i( \IA.Cc 1 S

In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
`j� ./
VI h, 001-fir I►lC.' I liaCtui 11;'A) ,S or
Financially Responsible Person L- 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.)
I I as) 2aZ3
DaAu tloI C` n -PP LS yr '1CS 7 60-t ;
Tiil J
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Signatur
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Type or Print Nam ,
N1?DES lAtiv \ Ik25 ) 2023
Title Date
i CImrnl ScuLt..vIck ' ,a Notary Public of the County of J"-i 0J` 2_ ,
State of North CaFolina hereby certifies
I ( OLC__\.: \ M(.,V\ S personally appeared before me this day and under
oath acknowledg€l that the above form was executed by him.
Witness my hand and notary seal,this 2 5 day of --aantACiXU.( , 2 0 2-3
(Notary Public) `}
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+ .•,„0`0.( SAthvo'I,,,�
My commission expires .J 1A`y '1 ZO�� �•`. Ctussiory''• F �%
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