NCC241141_FRO Submitted_20240506

FINANCIAL RESPONSUBULITY/O0MfNERSMXPFORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and on acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Smotion, N.C. Deportment of Environmental Cluo|ih/. Submit the completed honn to the appropriate
Regional Office. (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 biank.)
Part A.
V�'|�VV�CJ� �o���� ��J\�� ^'�� |���[OV����9�fs
1. Pn�ectNome ^ ""~^ ~ ' '` ' ^ ^' ^ ^ Improvements
'
��'ff Greenville
2. Location of|and-di�urbngaoUv�y County' `^^ CdyorTownship ~~ `'^
345O Blue Heron Dhve 85S1272 �7.8%473
Highway/Street Lati�udem°u°"/o°n=�* � Longitudew°u��o°y��)
��8�[U��7V �O��1
3. Approximate data land-disturbing aotiv�ywiUcomnnenue: February^ ^-~^- '
�
4. Purpose of development(residential, commercial, industrial, institutional,tutione|. etc.): Park
� �
5. Total acreage di�udzadcv uncovered (including of-o�eborrow and waste anaao): °'~
�
G. Amount of fee endomed: $ DO
-`=" . The application fee of$1UO.UO per acre(rounded
upto the next acre) ia assessed without a ceiling amount (Examp|e: 8.1U'ouna application fee iu$8OO).
Checks should bo addressed toNCOEO.
7. Has on erosion and sediment control plan been filed? Yea[] Enclosed GD No []
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mark Nottingham E-mail Address nnn8ftiOghG0@g[eeOVi|leOc.goV
���-����-�1��1�
Phone: O�hne# "-=°- ��� -`°~-`� Mobile#
8. Landowner(s) of Record (attach accompanied page to list additional owners):
City ofGreenville
Name Phone: Office# Mobile#
PO Box 7207
Current Mailing Address Current Street Address
Greenville, hJ�� �����
=F������^.��' . "= �' ���
Qh/ State Zip City State Zip
�1�l1� 1��1
10. OoedBookNo.-`" `'� PaQeNo. '°--` Provide a copy of the most current deed.
\`

Part B.
1. Company(iea)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 landonme/(s)is
an/ndividuaVs) the name(s)of the owner(s)may be listed as the financially responsible party(ies).
City of Greenville ' Parks and Recreation
Company Name E-mail Address
�MO� Cedar |
"_°"= =��=��� Lane
Current Mailing Address Current Street Address
Greenville, NC 27858
City State Zip City State Zip
���-����C�_�����
Phone: O�ue# �=� =�� -`=�' 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 n domestic company nagisbanod on the NC Secretary of State
business registry, 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
Phone: Office# yNubi|o#
Name of Individual to Contact(if Registered Agent io'acompany)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
cf the designated North Carolina agent who is registered mn 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 cf Individual to Contact(if Registered Agent ioacompany)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business An. If the Financially Responsible Party is on 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 OBAName
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 attorne}+in-fact, orif not an individuo|, bvmnofficer, dipmotur, partner' or registered agent with
the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected information should there be any change in the information provided herein.
F� ���f^ Director f Recreation
rf Parks
����� ��~^`������ ���P��^C�� 0' x ^���[����O[�� ���� / ��,vs
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Type or print name Title or Authority
8ignatu,P6 []ate
/n L' - �J y ���L
|. [�Ur'�V��� /-\y[7 . e Notary Public mf the <�wuntvof 7i-77
State of North Carolina, hereby certify that 7>m appeared personally
before me this day and being duly sworn acknowledged thaffhe above form was executed by him/her.
/
VVitnasan1y hand and notarial seal, this | doyof /~�/ON*����er- . 20
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11.
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- My oonnrnimeion expires