NCC231569_FRO Submitted_20230524

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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.
1. Project Name Co6.b/CS1-Occc.
2. Location of land-disturbing activity: County /P//7- City or Township C«C')Odic
Cr
Highway/Street2)oe f1-13 gew,',.t atitude Longitude
3. Approximate date land-disturbing activity will commence: OS - - otO
4. Purpose of development(residential,commercial, industrial, institutional, etc.): 22S/"C./2r ha/
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): Q /8
6. Amount of fee enclosed: $__ _ . The application fee of$100.00 per acre (rounded
to the tenth of acre)is assessed without a ceiling amount (Example:a 9-acre application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Car IDS JJ tcc vl E-mail Address
Telephone Cell#.252- ///2-v'19 r Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
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Name Telephone Fax Number
�i 5Co7T T 6' .5Co77- .s7
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
✓ t'IFa D€/ r.64Bto 84k4.a� belts - r/ ' g J Tr,cw0C'o/i
Name 1/4./ E-mail Address
G Sco1r ST
Current Mailing Address Current Street Address
City State Zip City State Zip
TelephonegS2 y/2- 291?7,5- Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 E-mail Address
Current Mailing 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 by any change in the information provided herein.
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Type or print name Title or Authority
R DE l osavd 3 J421imo C - /`/ -a0.23
Signature `l Date
I, yhS74-t:4 / JrZ , a Notary Public of the County of (Pr
ft—
State of North Carolina, hereby certify that Mal/I C3 OeL2flo "d De\ ravlo appeared
personally before me this day and being duly sworn acknowledged that tW above form was
executed by him.
Witness my hand and notarial seal, this )L1 day of 0_61,C1 , 20 2,3
Notary
Seal My commission expires 1,// 0/4ryi_.)