NCC220668_FRO Submitted_20220208

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)
Field Name
Description
Comments
PROJECT Tracking
number
Complete
Application Received date
Application/NOI
Commercial (30001) = 1542, Highway (30005) = 1611, Industrial (30002)
= 1541, Residential, Single Family Houses (SFE) = 1521, Residential,
SIC Code (Primary)
10
other than SFE (30000) = 1522, others = blank
Projector Site name
I� Pact
Site Street Address
f1
1 r or-k 131vd. W.
Site City
Wilson
Site County
Wilson
Site State
NC
Site Zip Code
'2,77 $9 (0
Non -Government = POF (default)
Government - County = CNG
Government - Federal = FDF
Site/Facility Type of
VOF
Government - Municipal = MWD
Ownership
Organization Government - State = STF
Approximate Activity
Start Date
Y 1 n 010,22
Total Acres of
Distrubance
FRO - First Name
X
"MUST be Financially Responsible Owner Person"
FRO -Last Name
C, �j +C.
"MUST be Financially Responsible Owner Person"
FRO - Organization
Formal Name
p L.LG
"MUST belong to Financially Responsible Owner"
FRO - eMail Address
vtc ►Yl(Aio mde tlo men . com
"MUST belong to Financially Responsible Owner"
FRO - Mailing Street
Address
0}3y-)3 "\daire 'V-,rm Rd
"MUST belong to Financially Responsible Owner"
FRO - Mailing
Supplemental Location
Text
NA
"MUST belong to Financially Responsible Owner"
FRO - Mailing City
r
"MUST belong to Financially Responsible Owner"
FRO - Mailing State
NC
"MUST belong to Financially Responsible Owner"
FRO - Mailing Zip Code
2"1513
"MUST belong to Financially Responsible Owner"
Latitude: Decimal
Degrees
Longitude: Decimal
� 2
Degrees
. IQ

(#) ACRES TO BE DISTURBED X $150.00 /ACRE=
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.)
In case of a violation please list the preferred contact (either the Financially Responsible Person or Registered Agent on the line
below:
i 19 , t.l- c
Financially Responsible Person
or
Registered Agent
9
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.)
Z / /zC
Date
Title or Authority j
le
Signature /
r E tf V t C.k
Type or Print Nam
Piz S' A".7 Z � zz.
Title Date
L `
a Notary Public of the County of State of North Carolina
hereby certifies
nally appeared before me this day and under oath acknowledged that the
above form was executed by him.
/Z f--
Witness my hand and notary seal, this _4/ day of %— o k� Zo Z Z.
(Notary Public)
My commission expires °Z !4 Z CHRISTINE OSEORNE
NOTARY PUBLIC
WAKE COUNTY, N.C.
MY Commission Expires 02-10-24