NCC230937_FRO Submitted_20230404

WILSON
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;3-14-2023
Application/N01
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521,Residential,
SIC Code(Primary) 30001 other than SFE(30000)=1522,others=blank
Project or Site name Bass Appliance
Site Street Address 3203 Airport Blvd.NW
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27896-8836
Non-Government=POF(default)
Government-County =CNG
Government-Federal=FDF
Site/Facility Type of Government-Municipal=MWD
Ownership POF Organization Government-State=STF
Approximate Activity
Start Date April 10,2023
Total Acres of
Disturbance 0.97 ACRES
FRO-First Name Hilton **MUST be Financially Responsible Owner Person**
FRO-Last Name Bass **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name Vernhill,LLC **MUST belong to Financially Responsible Owner**
FRO-eMail Address [e-mail] **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 3201 Airport Blvd.NW Suite"A" **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text **MUST belong to Financially Responsible Owner**
FRO-Mailing City Wilson **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27896-8836 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.7569
Longitude:Decimal
Degrees -77.9582

WILSON
NORtH
(#)ACRES TO BE DISTURBED 0.97 AC X$150.00/ACRE=$145.50
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:
Hilton Thomas Bass, Ronnie 1.Sutton, PE
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.)
3/13/07
Date
Member/Manager
Title or Authority
Signature
Hilton Thomas Bass; .
Type or Print Name
Presmerit 4). ---)Aft (711k4-r--,A‘f ----
Title Date
f le. /"I..Y►ltiihti ,a Notary Public of the County of t"GS ,State of North Carolina
hereby certifies 6
' 0(4-ah hOw)c.A laSS personally appeared before me this day and under oath acknowledged that the
above form was executed by him.Witness my hand and notary seal,this 13 4, day of MGrC h , ZOO .
1. \` :kl• f 4,
(Notary Public) ,�`".;!) T. ?�4/
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My commission expires -
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