NCC222489_FRO Submitted_20220712

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Department of
E n,,iirc:.nmental Quality
Feceived
APR [ 12022
01;n�-t:on-Salem
No person may initiate any land -disturbing activity on one or more acres as covered by thd; Apt_ b­ef6r`&ffFrie
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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Sandy Creek Outfall Phase V
1. Project Name
2. Location of land -disturbing activity: County Guilford/Randolph City or Township Unincorpated
Highway/street Starmount Road Latitude35.8663 Longitude-79.6205
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.93
6. Amount of fee enclosed: $ 800.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Boyd E-mail Address Brian. [e-mail]
Telephone [phone] Cell # 336-373-2055 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Greensboro 336-373-2055
Name Telephone Fax Number
PO Box 3136 2602 S. Elm -Eugene Street
Current Mailing Address Current Street Address
Greensboro NC 27402 Greensboro NC 27406
City State Zip City State Zip
10. Deed Book No. See Attached Page No. See Attached Provide a copy of the most current deed.
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.
City of Greensboro [e-mail]
Name
PO Box 3136
Current Mailing Address
Greensboro NC
City State
Telephone [phone]
E-mail Address
2602 S. Elm -Eugene Street
Current Street Address
2740 Greensboro NC 27406
Zip City State Zip
Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Virginia Spillman [e-mail]
Name of Registered Agent E-mail Address
PO Box 3136 2602 S. Elm -Eugene Street
Current Mailing Address Current Street Address
Greensboro NC 2740 Greensboro NC 27406
City State Zip City State Zip
Telephone [phone] 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.
Virginia Spillman
Type or print name
Sig unat re
Assistant Director, Water Resources, City of Greensboro
Title or Authority
3/Z
Date
I, LA tA YA M- &q S , a Notary Public of the County of G u I l 1 0 Vyt
State of North Carolina, hereby certify that V i r J i n i C1 Sp i It MOLVl appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
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SealVz
Zq !day of H a Yt'/h , 20 22
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Notary
My commission expires