NCC230630_FRO Submitted_20230310

Pitt County
�' Planning Department
Development Services Building
1717 W. 5th Street
�C Greenville, North Carolina 27834-1696
Telephone: [phone] James F. Rhodes, AICP
Director
Fax: [phone]
Financial Responsibility / Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land -disturbing activity on one or more contiguous acres as covered
by the Act before this form and an acceptable erosion and sedimentation control plan have been
completed and approved by the Pitt County Planning Department. (Please type or print and, if question is
not applicable, place N/A in the blank.)
Part A.
1. Project Name CMi Plastics
2. Location of land -disturbing activity: County
Pitt
City or Township Ayden , and Highway/Street Pepsi Wa„y, off NC 11 __
3. Approximate date land -disturbing activity will be commenced: Feb. 2023
4.
a
Purpose of development (residential, commercial, industrial, etc.): Industrial
Approximate acreage of land to be disturbed or uncovered: 6 Acres
6. Has an erosion and sedimentation control plan been filed? Yes X No
7. Person to contact should sedimentation control issues arise during land -disturbing activity: Name_
Steven Hasselbach
Telephone [phone] _
Landowner(s) of Record (Use blank page to list additional owners)
Hasselbach Management, LLC
Name(s) Name(s)
222 Pepsi Way 222 Pepsi Way
Current mailing address Street Address
Ayden NC 28513 Ayden
NC 28513
City State Zip City State
252-746-2171 252-746-2171
Telephone
9. Recorded in Deed BookNo. 2291
Part B.
1
Telephone
Page No. 833-837
Zip
Person(s) or firm(s) who are financially responsible for this land -disturbing activity (Use the
blank page to list additional persons or firms):
Hasselbach Management, LLC
Steven Hasselbach
Name of Person(s) or Firms (s)
Name(s)
222 Pepsi Way
222 Pepsi Way
Current mailing address
Street Address
Ayden NC 28513
Ayden NC 28513
City State Zip
City State Zip
252-746-2171
252-746-2171
Telephone
Telephone

2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
Name(s)
Current mailing address Street Address
City State Zip City State Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner (Use blank page to list additional partners):
Name(s) Name(s)
Current mailing address Current mailing address
City State Zip City State Zip
Telephone Telephone
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/her attorney -in -fact or if not an individual by an officer, director, partner, or
registered agent with 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.
�v6u-CtA5
Type or print name.��, Title or Aut unity 7
nature Date
1, it avi L. Fars' r a Notary Public of the County of \70+ State
of Nort Carolina, hereby certify that Stubheri �o��lua ilV1S511�C1n
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 Z 1 day of Dec-embev . 2011.
Notary
My commission expires Qft,bev 3,UZ�