NCC233651_FRO Submitted_20231212

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (Please type or print and, if the question is not applicable or the e-mail
and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name ABC Supply Co. #129
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Highway/Street Woodbridge Park Road Latitude Longitude
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.37 acres
6. Amount of fee enclosed: $ 200.00 . The application fee of$100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dan Bland-License Unlimited NC/SC E-mail Address [e-mail]
Telephone [phone] Cell# 919.291.1891 Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
American Builders&Contractors Supply Co Inc. N/A
Name Telephone Fax Number
P.O. Box 838 1 Abc Parkway
Current Mailing Address Current Street Address
Beloit WI 53512-0838 Beloit, WI 53511-4466
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
American Builders&Contractors Supply Co.. Inc.
Name E-mail Address
P. 1 Abc Parkway
Current Mailing Address Current Street Address
53512-0838 Beloit, WI 53511-4466
City State Zip City State Zip
Telephone _ Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Chad Bolt [e-mail]
Name E-mail Address
937 Woodridge Park Rd 937 Woodridge Park Rd
Current Mailing Address Current Street Address
Greenville, NC 27834 Greenville, NC 27834
City State Zip City State Zip
Telephone [phone] Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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 attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there by any change in the information provided herein.
CFO
Type or print name Title or Authority
1 r 1 FS/2 3
Signature Date
I, P-$3ECG/- LGE1144iN/ , a Notary Public of the County of e��
Wis Cats i✓1 la.00 /�(• BUCYL
State of 4o4fa- xoli a, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 18 th day of Mkt , 20 �3
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Notary
Seal : \C) ARY
My commission expires 3—vtr 7 2o25-
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