NCC240806_FRO Submitted_20240321

W I LSON
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: Wawa 6103 - Ward Blvd. & Nash St.
PROJECT LOCATION: 2650 Ward Blvd., Wilson. NC 27893
APPROXIMATE PROJECT START DATE: March 7, 2024
(#)ACRES TO BE DISTURBED 2.32 x$150.00/ACRE= 348.00
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.)
Wawa North Carolina. LLC
Name(Person or Firm)
260 W Baltimore Pike
Street Address(No P.O.BOX)
Wawa, PA 29063
City,State,Zip
800-444-9292
Telephone I1
N/A
Fax#
payman.nadimi(c�wawa.com
E-mail address
Registered agent for the person or firm who is financially responsible:
CT Corporation Systems
Name(Person or Firm)
4701 Cox Rd
Street Address(No P.O.BOX)
Glen Allen, VA 23060
City,State,Zip
804-217-7255
Telephone#
N/A
Fax#
N/A
E-mail address
PROJECT NAME: Wawa 6103 - Ward Blvd. & Nash St.

WILSON
•.:f r J�11 ,
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Wawa North Carolina, LLC 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.)
March 6, 2024
Dote
Title or Authorit
Signature
John Poplawski
Type or Print Name
Vice President
Title Date
MI.G1‘4.11 M D r t -'^ ,a Notary Public of the County of p e I4 W r✓G
State of Nefth ferelirte hereby certifies
Pc ;IIvs..4l ,l
J o I^r Po r A. 5 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 S day of !'f Ar L , 02 Q - .
(Notary Public) /{ ^
My commission expires 0 1 I 0 8 id 0.11
Commonwealth of Pennsylvania-Notary Seal
Michelle Morrison,Notary Public
Delaware County
My commission expires September 8,2027
Commission number 1436093
Member,Pennsylvania Association of Notdnes