NCC233514_FRO Submitted_20231128

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)
PROJECT NAME:Circle K-R&R 2723471 Wilson
PROJECT LOCATION:4940 Raleigh Road Pwkv W,Wilson. NC
APPROXIMATE PROJECT START DATE: ASAP
(#)ACRES TO BE DISTURBED 4 X$150.00/ACRE= $600-00
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.)
Circle K Stores. Inc:Meredith W. Rice,Jr.
Name(Person or Firm)
1100 Situs Court.Suite 100
Street Address(No P.O.BOX)
Raleigh, NC 27606
City,State,Zip
919-774-6700
Telephone#
Fax#
wrice(aa circlek.com
E-mail address
Registered agent for the person or firm who is financially responsible:
Name(Person or Firm)
Street Address(No P.O.BOX)
City,State,Zip
Telephone#
Fax#
E-mail address
PROJECT NAME: CIRCLE K - R&R 272341 WILSON

r
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Meredith W. Rice,Jr 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.)
Date
V1Ca- I)S2i; 1
Title o rity 7 _1
gnature
Meredith W.Rice.Jr.
Type or Print Name `
Vice President `7 -ZC�Z�-
Title Date
ReYa7r) F A l ,a Notary Public of the County of .h 1, '�s ,
State of North Carolina herebyce ifieth s
(✓v' C'e Jr'' personally appeared before me this day and under
oath acknowledged that the above form was�executed by him. ,
Witness my hand and notary seal,this T day of m���/22T ,A 6 A
(Notary Public)
ROBIN F. ALFORD
Notary Public, North Carolina
l/ h Johnston County
My commission expires T A3 c / �j 3 My Commission Expires
April 23,2023