NCC230536_FRO Submitted_20230302

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 and within the
corporate limits or the extraterritorial jurisdiction of the City of Burlington before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Burlington's
Erosion Control Administrator. (Please type or print, if the question is not applicable or the e-mail and/or fax
information unavailable, place NIA in the space provided. Blank spaces and/or inaccurate information will be
considered incomplete and could result in a disapproved plan.)
Part A.
Burlington-Alamance Regional Airport (BUY)
1 Project Name Runway 6-24 Rehabilitation and Apron Rehabilitation and Expansion
2. Location of land -disturbing activity: County Alamance City or Township__Buriington
Highway/Street Alamance Latitude 36.0488 Longitude-79.4767
3. Approximate date land -disturbing activity will commence: July 2023 _
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2T87
6. Amount of fee enclosed: $ 1,785 . The application fee of $225 for the initial 2 acres
plus $60 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-
acre application fee is $645).
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. Dan Danleley E-mail Address danftflyburlingtonnc.com
Telephone [phone] Cell # 336-212-2457 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Burlington Alamance Airport Authority NIA NIA
Name Telephone Fax Number
3441 N Aviation Drive 3441 N Aviation Drive
Current Mailing Address Current Street Address
Burlington NC 27215 Burlington NC 27215
City State Zip City State Zip
10. Deed Book No. 1249 Page No. 0093 Provide a copy of the most current deed.
11. Tax Map No. 12-2B-1 Block NIA Lot No. BAL Alamance Rd Airport
12. Parcel ID 120190 GPIN (State ID) 8863073341
Part B.
1. Person(s) or firm(s) who is financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Burlington Alamance Airport Authority danoflyburlingtonnc.com
Name E-mail Address
3441 N Aviation Drive 3441 N Aviation Drive
Current Mailing Address
Burlington NC 27215
City State zip
Telephone [phone]
Current Street Address
Burlinc ton NC 27215
City State Zip
Fax Number 336-227-6117

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 Email 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip
Telephone
City
Fax Number
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.
�D/N �D P f- E - i s Kc c1- -r r ✓C --b / P C' C r a l2
T le or pr name Title or Authority
Signature Date
a Notary Public of the County of RAWIXONIC C--?
State of North Carolina, hereby certify that hx) h"9z)1ele V appeared
personally before me this day and being duly sworn acknowled2fed that the above form was
executed by him.
Witness my hand and notarial seal, this A—D� day of .,�'p� its , 20�
X214w-,v,
Notary n
Seal
My commission expires
NOTARy
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