NCC241465_FRO Submitted_20240514

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 Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form 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 blank.)
Part A.
1. Project Name Wildwood Park - Observation Tower and Trails - Bid Package B
2. Location of land-disturbing activity: County Pitt City or Township Greenville
3450 Blue Heron Drive 35.6143 77.3222
Highway/Street Latitude(decimaldegrees) Longltude(decimaldegrees)
3. Approximate date land-disturbing activity will commence: December 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Recreational
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.0
6. Amount of fee enclosed: $ 100 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑x Enclosed 0 No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John Kuzenski, PE E-mail Address)[e-mail]
Phone: office# [phone] Mobile# NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Greenville [phone] NA
Name Phone: Office# Mobile#
PO Box 7207 2000 Cedar Lane
Current Mailing Address Current Street Address
Greenville NC 27835 Greenville NC 27858
City State Zip City State Zip
261
10. Deed Book No.4049, 4012 Page No. , 124 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).
City of Greenville-Recreation and Park;Mark Nottingham [e-mail]
Company Name E-mail Address
PO Box 7207 2000 Cedar Lane
Current Mailing Address Current Street Address
Greenville NC 27835 Greenville NC 27858
City State Zip City State Zip
Phone: office# [phone] Mobile# NA
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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:
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)
(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 should there be any change in the information provided herein.
Mirk offi/1 h 1 f ark5 C/a 44cr
Type or print name Title or Authority
/0 - 7-Zd22—
Sig nature Date
, a Notary Public of the County of
State of North Carolina, hereby certify that (Ark ID-t1� h(&►y appeared personally
before me this day and being duly sworn ackno ledged that'^ the ove form was executed by him/her.
Witness my hand and notarial seal, this 141 day of V60 r , 20 lira
Debra J. Nobles 1A t5
NOTARY PUBLIC
Pitt County atalith Carolina . 1
My Commission Expires February2,2027 My commission expires aoa
I!V,