NCC232354_FRO Submitted_20230807

WILSON
Nt,l/l .,.
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.21-666
Complete Application Received date
Application/N01
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521,Residential,
SIC Code(Primary) 1541 Light Industrial other than SFE(30000)=1522,others=blank
Project or Site name Sunnybrook Meat Processing
Site Street Address Horace Watson Road
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27893
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 Winter/Spring 2023
Total Acres of
Disturbance 1.55
FRO-First Name Hmoud **MUST be Financially Responsible Owner Person**
FRO-Last Name Awamleh **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name Monya,LLC **MUST belong to Financially Responsible Owner**
FRO-email Address [e-mail] **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 3180 Abbey Road **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text N/A **MUST belong to Financially Responsible Owner**
FRO-Mailing City Rocky Mount **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27804 **MUST belong to Financially Responsible Owner**
Latitude: Decimal
Degrees 35.691
Longitude:Decimal
Degrees -77.936

•
WILSON
JPTH CARO/INA
(#)ACRES TO BE DISTURBED 1.55 X$150.00/ACRE=$232.50($145.50 paid,$87.00 supplemental herewith)
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:
Hmoud Awamleh 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.)
3/ 9/ �. 3
Date
Managing Member
Title or Authority
Signature
Hmoud Awamleh
Type or Print Name
T t/fi�l , /i[/G1Zi ) a Notary Public of the County of 1 %%/S G State of North Carolina
hereby certifies
/,//n personally appeared before me this day and under oath acknowledged that the
above form was executed by him. �j
Witness my hand and notar eal,this �1 day of /Y/ - 2.. .
(Notary ublic)
My commission expires)/—/.
Steven Lee Oliverio
NOTARY PUBLIC
Wilson County,NC
My Commission Expires/1/6—.24Z3