NCC232503_FRO Submitted_20230821

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 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 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.1. Project NameAIRPORT WESTSIDE VEGETATION PROJECT
2. Location of land-disturbing activity: County FORSYTH City or Township WINSTON SALEM
Highway/Street 3801 N.LIBERTY STREET Latitude 36' 08' 27.75" N Longitude 80' 13' 16.19" W
3. Approximate date land-disturbing activity will commence:J U LY 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.) Airport
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.77 AC
6. Amount of fee enclosed: $ 600.00 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 _ EnclosedX
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name James Moose, P.E E-mail [e-mail]
Telephone [phone] Cell# 704-650-6050 Fax#
9 Landowner(s) of Record (attach accompanied page to list additional owners)
FORSYTH COUNTY 336-607-6121
Name Telephone Fax Number
201 N. CHESTNUT ST. 201 N. CHESTNUT ST.
Current Mailing Address Current Street Address
WINSTON SALEM, NC 27101 WINSTON SALEM, NC 27101
City State Zip City State Zip
10. Deed Book No. 1 298 Page No.1 365 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.
MARK DAVIDSON, AIRPORT DIRECTOR [e-mail]
Name E-mail Address
3801 N. LIBERTY STREET 3801 N. LIBERTY STREET
Current Mailing Address Current Street Address
WINSTON SALEM, NC 27105 WINSTON SALEM, NC 27105
City State Zip City State Zip
Telephone [phone] Fax Number 336-767-6361

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 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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
MARK DAVIDSON AIRPORT DIRECTOR
Type or print name Title or Authority
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I, __caa /�/� o, , a Notary Public of the County of J f' r:5•,4-
/� appeared
of North Carolina, hereby certify that Nall, 2tbQ4c2,4
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 g/ day of , 20 4
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