NCC222205_FRO Submitted_20220615

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place NIA in the blank).
Part A:
1. Project Name: Bennington Village - Section 4 - Phase 4
2. Location of land -disturbing activity: " "' v' ' "' ""' "' '
3. Approximate date land disturbing activity will be commenced: June 2022
4. Development type: Commercial_ Industrial_ Institutional_ MF residential_ SF residential X
5. Approximate acreage of land to be disturbed: 6.9
6. Has an erosion and sediment control plan been filed? Yes X No
7. Landowner(s) of Record (attach pages to list additional owners):
[phone] [e-mail]
Name Telephone Email
P.O Box 9846 201 S. Elm Street - Ste. 201
Current Mailing Address
Greensboro NC
City State
Current Physical Street Address
27429 Greensboro NC 27401
Zip City State Zip
8. Deed County: Book: Page:
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Ken Chavis Telephone: [phone]
E-mail: [e-mail] Other:
Part B:
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive
list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship the name of the owner
or manager may be listed as the financially responsible party.
Same as owner above
Name
Current Mailing Address
City State
Telephone Email
Current Physical Street Address
Zip City State Zip

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
Telephone Email
Current Mailing Address
Current Physical Street Address
City State Zip
City State Zip
(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:
Carrolland Corporation
[phone] [e-mail]
Name
Telephone Email
P.O. Box 9846
201 S. Elm Street - Ste. 201
Current Mailing Address
Current Physical Street Address
Greensboro NC 27429
Greensboro NC 27401
City State Zip
City State Zip
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.
Al Leonard
VP - Carrolland Corporation
Type or prin/na
Title or Authority
Signatu
Date
r
a Notary Public of the County of � 1 '� i i ��C,
State of �� w Y`� �'� �_ (� Vt I Cl tt hereby certify that t ` 'y ti f-k_ v
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, this �: �ay of N' Y '� �ti , 20 ?_
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My Commission exoires
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