NCC243086_FRO Submitted_20241007

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Project Harbor
1. Project Name
2. Location of land-disturbing activity: County Wi lSon City or Township Wilson
Highway/Street Corporate parkway Latitude 35.7407 Longitude-77.9939
3. Approximate date land-disturbing activity will commence: 1 0-8-2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 93.50
6. Amount of fee enclosed: $ 9,400 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Patrick Nichols E-mail Address [e-mail]
Telephone n/a Cell# 207-831 -4090 Fax# n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wilson County Properties Inc 252-237-1115 n/a
Name Telephone Fax Number
108 Barnes St W
Current Mailing Address Current Street Address
Wilson NC 27893
City State Zip City State Zip
10. Deed Book No. 1 726 Page No.226 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Wilson County Properties Inc [e-mail]
Name E-mail Address
108 Barnes St W
Current Mailing Address Current Street Address
Wilson NC 27893
City State Zip City State Zip
Telephone [phone] Fax Number n/a

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Jennifer J Lantz Corporate Secretary
Type or print name Title or Authority
10-03-2024
Si atu Date
I, Eatu72 7�- ��ca(�I,p(ite_ , a Notary Public of the County of (,{.//�Lsoh
State of North Carolina, hereby certify that J i'1Yl%kr (T / l-2 f Z appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
rd /
Witness my hand and notarial seal, this 0 — day of 0C1OL,/ , 20 Aaq
W/zLeiiaoht-e
"OFFICIAL SEWNotary
Y ,� Croika
,t y DAWNB.BREEDLOVE My commission expires 9 '� 26
Mr Carmubn Ewws otirratc;:.,e