NCC233377_FRO Submitted_20231113

ca Pitt County
,tip °4*� Planning Department
Development Services Building
\� E. 3 1717 W. 5th Street
�,�►� Greenville,North Carolina 27834-1696 James F.Rhodes,AICP
Telephone:[phone] Director
Fax:[phone]
Financial Responsibility /Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land-disturbing activity on one or more contiguous acres as covered by the Act
before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Pitt County Planning Department.(Please type or print and,if question is not applicable,place N/A in the blank.)
Part A.
1. Project Name ENC Food Commercialization Center
2. Location of land-disturbing activity: County Pitt
City or Township Ayden ,and Highway/Street SR 1180 Anderson Truss Rd
3. Approximate date land-disturbing activity will be commenced: Dec 2023
4. Purpose of development(residential, commercial, industrial, etc.): Industrial
5. Approximate acreage of land to be disturbed or uncovered: 6 Acres
6. Has an erosion and sedimentation control plan been filed? Ycs X No
7. Person to contact should sedimentation control issues arise during land-disturbing activity: Name
Keith Purvis Telephone [phone]
8. Landowner(s)of Record (Use blank page to list additional owners):
Eastern North Carolina Food Eastern North Carolina Food
Commercialization Center Commercialization Center
Name(s) Name(s)
4144 B West Ave 4144 B West Ave
Current mailing address Street Address
Ayden NC 28513 Ayden NC 28513
City State Zip City State Zip
252-758-1700 252-758-1700
Telephone Telephone
9. Recorded in Deed Book No. 4348 Page No. 562
Part B.
I. Person(s)or firm(s)who are financially responsible for this land-disturbing activity (Use the
blank page to list additional persons or firms):
Eastern North Carolina Food Keith Purvis
Commercialization Center
Name of Person(s)or Firms(s) Name(s)
4144 B West Ave 4144 B West Ave
Current mailing address Street Address
Ayden NC 28513 Ayden NC 28513
City State Zip City State Zip
252-758-1700 252-758-1700
Telephone Telephone

2. (a) If the Financially Responsible Party is a Corporation,give name and street address of
the Registered Agent.
Name(s)
Current mailing address Street Address
City State Zip City State Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner(Use blank page to list additional partners):
Name(s) Na me(s)
Current mailing address Current mailing address
City State Zip City State Zip
Telephone Telephone
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/her attorney-in-fact or if not an individual by an officer, director, partner, or
registered agent with authority to execute instruments for the financially responsible person). I
agree to provide corrected information should there be any change in the information provided
herein.
Keith Purvis 'Pit`Ed.MUD or
'fv a name Title drAuthority J
la/U
Stgnatr! Date
W ar W. ,a Notary Public of the County of i° ff State
of orth Carolina, hereby certify that ICeN A4rVi 5
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him. I
Witness my hand and notarial seal this 6 day o f OC-7 v . 20 2 3.
/ /viir
Notary
T� My commission expires q/j,/L026
z /
z
'°�et_lc
G
�COUNr4'‘‘