NCC242532_FRO Submitted_20240822

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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: WaWa -#6011 1600 Forest Hills Road and Tarboro Street
PROJECT LOCATION: 1600 Forest Hills Road Wilson, NC 27893
APPROXIMATE PROJECT START DATE:September 2024
(#)ACRES TO BE DISTURBED 2.45 X$150.00/ACRE= $367.50
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.)
Wilson (Forest Hills)ARD CGP, LLC
Name(Person or Firm)
361 Summit Boulevard Suite 110
Street Address(No P.O.BOX)
Birmingham, AL 35243
City,State,Zip
602-908-1424
Telephone#
Fax#
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
National Registered Agents
Name(Person or Firm)
160 Mine Lake Ct
Street Address(No P.O.BOX)
Raleigh, NC 27615
City,State,Zip
602-908-1424
Telephone#
Fax#
E-mail address
PROJECT NAME: WaWa -#5911 1600 Forest Hills Road and Tarboro Street

WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Chad J. Post 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.)
August 4,2023
Date
Authorized Agent
Titlerathsl,c9
\J i
Signatwte
Chad J.Post
Type or Print Name
Authorized Agent August 4,2023
Title Date
Fli7aheth Pilgrim ,a Notary Public of the County of
Jefferson ,State of ALABAMA hereby certifies
Chad J. Post 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 4th day of August 2023 •
(Notary Public) --RifyyvyyA
My commission expires ELIZABETH PILGRIM
NOTARY PUBLIC,ALABAMA STATE AT LARGE
MY COMMISSION EXPIRES NOV.12,2024