NCC221309_FRO Submitted_20220405

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. Petco Kinston NC
1. Project Name
2. Location of land -disturbing activity: CountyLenolr City or Township Kinston
Highway/Street Hill Farm Rd Latitude 35°15'45.87"N Longitude 77038'55.91 "W
3. Approximate date land -disturbing activity will commence: 03/1 1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):1.36
6. Amount of fee enclosed: $ 200.00 . 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? YesX No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameBrian Kemp E-mail [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Perry Brothers Properties, LLC 252.523.5107
Name
PO Drawer 1475
Current Mailing Address
Kinston, NC 28503
City State
10. Deed Book No. 1873
Zip
Page No.
Telephone
518 Plaza Blvd.
Current Street Address
Kinston, NC 28501
City
750
State
N/A
Fax Number
Zip
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.
PC -Kinston, NC-1-UT, LLC [e-mail]
Name
4747 Williams Drive
Current Mailing Address
Georgetown, TX 78633
City
E-mail Address
4747 Williams Dr.
Current Street Address
Georgetown, TX 78633
State Zip City
Telephone [phone] Fax Number N/A
State
Zip

(a) If the Financially Responsible Party Is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent.
Cogency Global Inc.
Name
212 South Tryon Street Ste 1000
Current Mailing Address
Charlotte, NC 28281-0001
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
212 South Tryon Street Ste 1000
Current Street Address
Charlotte, NC 28281-0001
City State Zip
Fax Number 866.775.0115
(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
Current Mailing Address
City
Telephone,
E-mail Address
Current Street Address
Zip City State ZipT
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.
Gabriel Martinez
Type or pri
&,*"5
Project Manager
Title or Authority
02.24.2022
Date
a Notary Public of the County of L(l,//ra,.rsaA
State of North Carolina, hereby certify that 6A�ri�_/ Y,4r-1rrraz appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this -?'K or- day of-��ir� _, 20?.Z
��{►�Y p4e ; TERESA T. ADAMS
=r, S Notary Public, State of Texas
Comm. Expires08-30-2025 Notary
S
M0,V�` Notary ID 12541661-9
My commission expires_