NCC222840_FRO Submitted_20220830

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 Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name PTIA Runway Rehabilitation 5R-23L Phase 4
2. Location of land -disturbing activity: County Guilford City or Township Greensboro
1000A Ted Johnson Pkwy 36.101 79.941
Highway/Street Latltude(decimalaegrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: May 09, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Aviation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 84 (1 4 new)
6. Amount of fee enclosed: $ 1 ,400 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lorin Akins E-mail Address [e-mail]
Phone: Office # 336.665.5600 Mobile #
0
Landowner(s) of Record (attach accompanied page to list additional owners):
Piedmont Triad International Airport 336.665.5600
Name Phone: Office # Mobile #
1000A Ted Johnson Pkwy 1000A Ted Johnson Pkwy
Current Mailing Address
Greensboro NC 27409
City
State Zip
Current Street Address
Greensboro NC 27409
City
State
Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Piedmont Triad Airport Authority [e-mail]
Company Name
1000A Ted Johnson Pkwy
Current Mailing Address
Greensboro NC 27409
City State
Phone: Office # 336.665.5600
E-mail Address
1000A Ted Johnson Pkwy
Current Street Address
Greensboro NC 27409
Zip City
Mobile #
State
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address
City State
Phone: Office #
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
N/A
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
ofthe Certificate ofAssumed Name.
The above information iotrue and correct tothe best ofnlyknowledge andbeliafendvvaso[ovided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorDmy-in-faot, or if not on individual, by an offine[, director, podncr, or registered agent with
the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected information should there beany change inthe information provided heroin.
Lorin Akins
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Deputy -/ Director - Construction
Type orprint name Title orAuthority
(-
Signature Date
[ a Notary Public of the County of 4'�'t "-%tr4
State ofNorth Carolina, hereby certify that
before nnethis day and being duly sworn acknowledged that the above form was executed oyn|rn/ner.
Witness Dlyhand and notarial seal, this day of tEUAye, .20_,a��__
�MMMMSM EXPIKS My commission expires lo
oh Pusuc��
'Y

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
N/A
Name
Current Mailing Address
City State
Deed Book No.
Landowner 3 of Record:
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No._
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item I in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State
Mobile #
Zip
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #