NCC221966_FRO Submitted_20220525

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing modvhy on one or more acres on 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 bzthe
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
urfax information unavailable, place N/A inthe b|onk.)
Part A. �����,����'|'f��f����K�Uf�,��l�8�3ron
1. Pn�ectName
Rehabilitate ' ' `~/'/~ ~ South ' ~�" " Apron
BUOOODlh�� /�Shey'||��
2. LooeUnnofland-disturbing aoUvih/: Coun City urTmwnoh| /''
Highwav/Street 61 Terminal D[ Lohtud 35-26-04'0 N Longitud 82-32-33'82 W
3. Approximate date land -disturbing activity will commence: ~ ]UOe 2022
4. Purpose ofdevelopment (nenidenho|.commercial, industrial, inaUhudj
institutional, : Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.4
8. Amount offee enclosed: 50000 application fee of$1O0.UD per acre
(rounded uphothe next acre) iaassessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has anerosion and sediment control plan been filed? Yes '^ No Enclosed
O. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nam |E3redMe[['|| E-mail Addnsa 'me[['||@f|yaV|'co[0
Ta|ephon /828\2O9-5113 Cell #[phone] Fax# /828\684-3404
0. Landowner(s) of Record (attach accompanied page to list additional owners):
Greater Asheville Regional Airport Authority /828\ 684-2226 /828\ 684-3404
Name Telephone Fax Number
61 TerOl'O8| [l['Ve' Suite 1 61 Terminal [][iVe. Suite 1
Current Mailing Address Current Street Address
Fletcher NC 28732 Fletcher NC 28732
City State Zip City State Zip
����� 1i{���_1�n��
10� DeedBookNo =^^== Page No. ' '°`^ '"-=`° Provide acopy ofthe most current deed.
PmrtB'
1. Cnmpony(ieo) or Dnn(o) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the companyorfirm ioosole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Greater Asheville Regional /\i[pU[t [0Pe'80Oan@f|VaV|'co[0
Name E-mail Address
61 T8[0iO8l D[iVe, Suite 1 61 T8[DliO@l D[iVe, Suite 1
Current Mailing Address Current Street Address
Fletcher NC 28732 Fletcher NC 28732
City State Zip city State Zip
/����\����1_���� (A28)68�-����
Te|ephun \�^-~^/ "�-` ^^"-�= FonNumber' ~' '

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:
N/A
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
N/A
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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 be any change in the information provided herein.
Lew Bleiweis, A.A.E. Executive Director
Type or print name
Signature
Title or Authority
Date
n%` Pf1n1D d , a Notary Public of the County of
State of North Carolina, hereby certify that yve-V appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
fir
Witness my hand and notarial seal, this i day of 7GhnVkfy 20 c�
ELLEN M HEYWOODi
NOTARY PUBLIC Notary
DERSON COUNTY, NC a
►* bnEVkw&10-2024 My commission expires