NCC243345_FRO Submitted_20241031

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville(Title 9, Chapter 8)before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Greenville,
Engineering Department. (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 Azura Vascular Care
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Highway/Street Emerald Place Dr. Latitude(decimal degrees)35.600 Longitude(decimal degrees) -77.406
3. Approximate date land-disturbing activity will commence: December 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.00
6. Amount of fee enclosed: $ 200.00 . The application fee of$100.00 per acre or portion
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre
application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed X No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Timothy Nifong, PE E-mail Address [e-mail]
Phone: Office# 252-558-0888 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
G.N.B. Investments, LLC
Name Phone: Office# Mobile#
2465 Emerald Place 2465 Emerald Place
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville NC 27834
City State Zip City State Zip
10. Deed Book No. 1841 Page No. 528 Provide a copy of the most current deed.
1841 525

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).
ENA Investment Properties, LLC [e-mail]
Company Name E-mail Address
3800 E 10th Street, Ste 201 3800 E 10th Street, Ste 201
Current Mailing Address Current Street Address
Greenville NC 27858 Greenville NC 27858
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
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 a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
M. Carney Taylor, M.D. [e-mail]
Name of Registered Agent E-mail Address
3800 E 10th Street, Ste 201 3800 E 10th Street, Ste 201
Current Mailing Address Current Street Address
Greenville NC 27858 Greenville NC 27858
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
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.
M. Carney Taylor, M.D. Manager
Type or print name Title or Authority
int Ci4Arti "----4-, Viti /7E>ag-
Signature Date
I, -3Om t. L VQ'ck , a Notary Public of the County of PA
State of North Carolina, hereby certify that A.Co$,1ell -Ml0 f, ' b appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 1 1 day of ,7fe iv,,je►r , 20.2-1
r J, &
Jamie L.Vick
,..;NOTARY PUBLIC Nota
''fiiftCounty,NC I I C, 2 0Z S
My Commission Expires April 10,2025 My commission expires Y'i