NCC221430_FRO Submitted_20220503

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 Name City of Wilson PH 2 Greenway Improvements
Location of land -disturbing activity: County Wilson City or Township Wilson
Highway/Street Canal Drive Latitude 35.741238 Longitude-77.931981
Approximate date land -disturbing activity will commence: October 30, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): recreational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.5 acres
6. Amount of fee enclosed: $195.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No x Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dale Edmonds E-mail Address [e-mail]
Telephone [phone] Cell # 252-205-9925 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Wilson 252-399-2465
Name
P.O. Box 10
Current Mailing Address
Wilson NC 27893
City State
10. Deed Book No. 1611
Part B.
1
Telephone
112 Goldsboro St E
Current Street Address
Wilson NC
Zip City
State
252-399-2453
Fax Number
27893
Zip
Page No. 639 Provide a copy of the most current deed.
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.
City of Wilson (Bill Bass) [e-mail]
NamgDirector of Public Works/City Engineer)E-mail Address
P.O. Box 10 112 Goldsboro St E
Current Mailing Address Current Street Address
Wilson NC 27893 Wilson NC 27893
City
State
Zip City
State
Zip

Telephone [phone]
Fax Number 252-399-2453
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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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
E-mail 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.
Bill Bass
Type or print name
Director of Public Works/City Engineer
itle or Authority
' , li 712,1
S i g n1afure Date
I, LYd r�LQJ a Notary Public of the County of W`sm
State of North Carolina, hereby certify that �01� �li��S appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness rr iiF;�Xarial seal, this ��I day of 20 _
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MY EXPIRES A4A
coMs120 V Notary
*2 gUs '-k? My commission expires � 1 l _ L�11,
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