NCC232532_FRO Submitted_20230822

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'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)
WAWA - #5904 WARD BOULEVARD & NASH STREET
PROJECT NAME:
PROJECT LOCATION: 2650 Ward Boulevard Wilson, NC 27893
APPROXIMATE PROJECT START DATE: January 30th, 2023
(#)ACRES TO BE DISTURBED 1.99 X$150.00/ACRE= $298.50
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.)
2091 Nash Wilson LLC
Name(Person or Firm)
2950 SW 27th AVENUE, SUITE 300
Street Address(No P.O.BOX)
Miami, FL 33133
City,State,Zip
[phone]
Telephone#
Fax#
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
Corporation Service Company
Name(Person or Firm)
2626 Glenwood Ave Ste 550
Street Address(No P.O.BOX)
Raleigh, NC 27608
City,State,Zip
800-927-9800
Telephone#
Fax#
E-mail address
PROJECT NAME: WAWA-#5904 WARD BOULEVARD&NASH STREET

In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
2091 Nash Wilson LLC 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.)
12/5/22
Date
Member
Title or Authority
7. ./>-2----1
Si ure
James Leach
Type or Print Name
Member 12/5/22
Title Date
._)ifi r) ` al I riq ,a Notary Public of the County of 01 t t ) t J
State of Nt,.111 Caar ulli id hereby certifies
-liter , -e,5 l Ch personally appeared before me this day and under
oath acknowledged that the above form was executed by him.
(DeWitness my hand a - a sepJ,.th' v. day of C943?-1D----
(Notary Public)
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