NCC223975_FRO Submitted_20221130

t,�ATH CAROLIN
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
Bartlett Job No. 22-604
Complete
Application/NO]
Application Received date
SIC Code (Primary)
1521
Commercial (30001) = 1542, Highway (30005) = 1611, Industrial (30002)
= 1541, Residential, Single -Family Houses (SFE) = 1521, Residential,
other than SFE (30000) = 1522, others = blank
Project or Site name
Bright Leaf — Phase I
Site Street Address
Heritage Drive
Site City
Wilson
Site County
Wilson
Site State
NC
Site Zip Code
27893
Site/Facility Type of
Ownership
POF
Non -Government = POF (default)
Government -County = CNG
Government - Federal = FDF
Government - Municipal = MWD
Organization Government - State = STF
Approximate Activity
Start Date
Winter 2022
Total Acres of
Disturbance
10.89
FRO - First Name
Raymond
"MUST be Financially Responsible Owner Person"
FRO -Last Name
Rinker
"MUST be Financially Responsible Owner Person"
FRO - Organization
Formal Name
Starlight Homes North Carolina, LLC
"MUST belong to Financially Responsible Owner"
FRO - Email Address
[e-mail]
"MUST belong to Financially Responsible Owner"
FRO - Mailing Street
Address
402S Lake Boone Trail, Ste. 200
"MUST belong to Financially Responsible Owner"
FRO - Mailing
Supplemental Location
Text
N/A
"MUST belong to Financially Responsible Owner"
FRO - Mailing City
Raleigh
"MUST belong to Financially Responsible Owner"
FRO - Mailing State
NC
"MUST belong to Financially Responsible Owner"
FRO - Mailing Zip Code
27607
"MUST belong to Financially Responsible Owner"
Latitude: Decimal
Degrees
35.728
Longitude: Decimal
Degrees
-77.962

NORTH CAROLING
(#) ACRES TO BE DISTURBED ;.87 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:
Raymond Rinker Or
Financially Responsible Person Registered Agent
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! �/, Mz d _ZZ
Date
Vice President of Land Development
Title or Authority -
Signatur
Raymond Rinker
Type or Print Name
1AW�[i N, a Notary Public of the County of State of North Carolina
hereby certifie Loni �V (f (� 1
1P of` �ul� I� ersonally appeared before me this day and under oath acknowledged that the
abov_ form was executed by him.
Witness my hand and notPi al, this day of
(Notary Public)
My commission expires,: MARY HILL HEROLD
NOTARY PUBLIC
WAKE COUNTY, NC
My Commission Expires 9-24-2026