NCC192835_MODIFICATION Supporting Doc Revised FRO_20210326

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Environment and Natural Resources. (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 Name: Fayetteville Regional Airport Terminal Improvements — Phase 2
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street SR 2260/Airport Road Latitude 34.993882' Longitude-78.887136°
3. Approximate date [anddisturbingactivity will commence: October 2019
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste 4.7 acres 1 acre
areas): (staging area Part 1)
6. Amount of fee enclosed: Previously Paid The application fee of $65.00 per acre (rounded up to the
next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585 00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Toney Coleman Airport Director Email [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Fayetteville 910-433-1160
Name (Toney Coleman, Airport Director) Telephone Fax Number
433 Hay Street
Current Mailing Address Current Street Address
Fayetteville, NC 28301
City State Zip City State Zip
10. Deed Book No. 4940 Page No. 845 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
_City of Fayetteville tcoleman(mci.fay.nc.us
Name Email Address
433 Hay Street
Current Mailing Address Current Street Address
Fayetteville, NC 28301
City State Zip City State Zip
Telephone# [phone] Fax#

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
ofthe designated North Carolina Agent:
N/A
Current Mailing Address
Zip
Telephone #
Email Address
Current Street Address
City State Zip
Fax #
(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
Current Mailing Address
State
Telephone #
Email Address
Current Street Address
City State Zip
Fax #
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 attomey-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.
Type or print name Title or Authority
3/1g'/Z'
Date
I, En`r'r �. L,h(fP /1 , a Notary Public of the County of CI m flf Ul d,
State of North Carolina, hereby certify that /yAie� rz- /yP+ &Z man appeared personally
before me this day and being duly sworn acknowledged thatthe above form was executed by him.
Witness my hand and notarial seal, this IqA day of /eta (C,fl 2021.
ota
TRY141A L. WOLFE
M commission expires
Notary Public, North Carolina y P
Cumberlantl County
My Commission Ex ires
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