NCC241916_FRO Submitted_20240624

WILSON
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:Gregory's Storage
PROJECT LOCATION:2024 Westwood Ave. W., 35.733, -77.954
APPROXIMATE PROJECT START DATE:Winter 2024
(#)ACRES TO BE DISTURBED 0.62 X$150.00/ACRE=$93.00
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.)
Glendy E. Gregory
Name(Person or Firm)
2403 Nash St. NW, Ste. A
Street Address(No P.O.BOX)
Wilson, NC 27896
City,State,Zip
252-205-6793
Telephone#
N/A
Fax#
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
Glendy E. Gregory
Name(Person or Firm)
2403 Nash St. NW, Ste. A
Street Address(No P.O.BOX)
Wilson, NC 27896
City,State,Zip
252-205-6793
Telephone#
N/A
Fox#
[e-mail]
E-mail address
PROJECT NAME: Gregory's Storage

WILSON
at.
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Glendy E. Gregory 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.)
Date
Owner
Tit,: fthorit c
Signature D//✓���) ifier
Glendy E. Gregory
Type or Print Name
"0"1.4.,•<-/�I .f.� 1J,,ed") a Notary Public of the County of P-A—S-dly
State
e
oof lNo_�rth Carolina hereby certifies
',4r �J � personally appeared before me this day and under
oath acknowledged that the above form was a ecuted by him.
Witness my hand and notary seal,this_ // day of di./0,4li, ,.<r✓�.
(Notary Public. _~
Steven Lee Oliverio
My commission expires/1—/ 4245 . NOTARY PUBLIC
Wilson County,NC
My Commission Expires //i'202.&