NCC223931_FRO Submitted_20221123

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Gi!FFN
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 N/A in the blank).
Part A:
1. Project Name: Guilford College Road Infrastructure
2. Location of land -disturbing activity: 515 Guilford College Road
3. Approximate date land disturbing activity will be commenced: October 2022
4. Development type: Commercial ✓ Industrial Institutional MF residential SF residential
5. Approximate acreage of land to be disturbed: 26.63
6. Has an erosion and sediment control plan been filed? Yes ✓ No
7. Landowner(s) of Record (attach pages to list additional owners):
NC Grensboro Guilford, LLC 864-263-5431
Name
201 Riverplace, Suite 400
Current Mailing Address
Greenville SC
29601
Telephone
e'ackson realt linkdev.i ,
Email
Current Physical Street Address
City State Zip City State
8. Deed County: Guilford Book: 8561 Page: 709
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Eric Jackon Telephone: [phone]
E-mail. e'ackson realt linkdev.com Other:
Zip
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.
NC Greensboro Guilford, LLC
Name
201 River lace, Suite 400
Current Mailing Address
Greenville SC 29601
City State
Zip
864-263-5431
Telephone
e'ackson realt linkdev.t i
Email
Current Physical Street Address
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:
Corporation Service Company
Name
Telephone Email
2626 Glenwood Ave Ste 550
Current Mailing Address
Current Physical Street Address
Raleigh NC 27608
_
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:
Name
Telephone Email
Current Mailing Address
Current Physical Street Address
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.
Philip J Wilson
Type or print n me
Signature
Manager
Title or Authority
r 2' y
Date
a Notary Public of the County of
evwlili�
State of k ti�� hereby certify that j,
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,
7�
this day of 20
My Commi sion Expires
My Commission expires June 26 2025
NOTA1, •��'
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