NCC241223_FRO Submitted_20240419

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 Department. (Please type or print and, if the question is not applicable or the e-mail address or
phone number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Children's Health Services
2. Location of land-disturbing activity: County_ Pitt City or Township Greenville
Highway/Street NC Hwy 33 E Latitude(decimaldegrees) 35.585 LOngitUde(decimaldegrees) -77.312
3. Approximate date land-disturbing activity will commence: July 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Medical
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.00
6. Amount of fee enclosed: $200.00 _. The application fee of$100.00 per acre or portion
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre
application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bryan C. Fa�-aundus, P.E. E-mail Address [e-mail]
Phone: Office# 252-565-1024 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
CHS Properties, LLC 252-329-7337
Name Phone: Office# Mobile#
1826 W. Arlington Blvd. 1826 W. Arlington Blvd.
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville NC 27834
City State Zip City State Zip
10. Deed Book No. 4419 Page No. 674 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
CHS Properties, LLC mharris,r!chspeds.org
Company Name E-mail Address
1826 W. Arlington Blvd. 1826 W. Arlington Blvd.
Current Mailing Address Current Street Address
Greenville _ NC 27834 Greenville NC 27834
City State Zip City State Zip
Phone: Office# 252-329-7337 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Christopher Ozimek [e-mail]
Name of Registered Agent E-mail Address
1826 W. Arlington Blvd. 1826 W. Arlington Blvd.
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville NC 27834
City State Zip City State Zip
Phone: Office# 252-329-7337 Mobile# [phone]
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# _ Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership,or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information s Id there be any change in the information provided herein.
Christopher Ozimek _ Owner Manager
Type or print name ' Title or Authority
7)1412'
Signature Date
I, J(SC'co.. ` S , a Notary Public of the County of 'c
State of North Carolina, hereby certify that Gnins4o1her Ott v elL appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this ' day of 'VIO►YGIr1 , 20 24
JessiN Bryson Hems
Pitt Public
ivotary
Beth Carolina
My Commission Exp res i t) ' My commission expires "+&O UGh I41 2.02A