NCC232858_FRO Submitted_20230925

WILSON,
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.22-256
Complete Application Received date -
Application/N01
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 Sun River Service Corp.
Site Street Address Beeler Rd.S./Tolson Rd.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 Gov ernment-State=STF_
Approximate Activity
Start Date Summer/Fall 2023
Total Acres of
Distrubance 1
FRO-First Name John Jefferson **MUST be Financially Responsible Owner Person**
FRO-Last Name Ross **MUST be Financially Responsible Owner Person*"
FRO- Organization
Formal Name Protein for Pets OpCo,LLC **MUST belong to Financially Responsible Owner**
FRO-eMail Address jrossCcDsunriverservice.corn **MU51 belong to Financially Responsible Owner**
FRO-Mailing Street
Address 2018 Beeler Rd.S. **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 27893 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.699
Longitude:Decimal
Degrees -77.920

WILSON
40
(ii)ACRES TO BE DISTURBED 1 X$150.00/ACRE=$150.00
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:
John Jefferson Ross 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.)
IL S 4- Zo Z 3
Date
President, Protein for Pets OpCo, LLC
Title or Authority 1 v t/'.( �
J
Signature
John Jeffersonoss
Type or Print Name
1
I,/t1#,erU ,a Notary Public of the County of `/G-SU't.) State of North Carolina
hereby certifies
l/ /y a-/I-I1,6e.)()Al SS personally y appeared before me this day and under oath acknowledged that the
above form was executed by him. �� D
Witness my hand and nota eal,this /2- day of c 6/ �/tze..0 . .2023 .
(Notary Public)
Steven Lee Oliverio
My commission expires///h 24.Z3 . NOTARY PUBLIC
Wilson County,NC
My Commission Expires///?Z 23